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Doctoral Thesis

Cognitive-motor interventionsA novel approach to improve physical functioning in older adults

Author(s): Pichierri, Giuseppe

Publication Date: 2014

Permanent Link: https://doi.org/10.3929/ethz-a-010104076

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DISS. ETH NO. 21604

Cognitive-motor interventions

–

A novel approach to improve physical

functioning in older adults

A thesis submitted to attain the degree of

DOCTOR OF SCIENCES of ETH ZURICH

(Dr. sc. ETH Zurich)

Presented by

GIUSEPPE PICHIERRI

MSc ETH HMS

born on 06.07.1979

citizen of Niederglatt (Zurich) and Italy

accepted on the recommendation of

PD Dr. Eling D. de Bruin

Prof. Dr. Kurt Murer

Prof. Dr. David P. Wolfer

2014

Table of Contents

Chapter 1 General Introduction 7 – 24

Chapter 2 Use of virtual reality technique for the training of motor

control in the elderly – Some theoretical considerations

Article published in Z Gerontol Geriat 2010, 43:229–234

25 – 41

Chapter 3 Cognitive and cognitive-motor interventions affecting

physical functioning: a systematic review

Article published in BMC Geriatrics 2011, 11:29

43 – 87

Chapter 4 The effects of a cognitive-motor intervention on voluntary

step execution under single and dual task conditions in

older adults: a randomized controlled pilot study

Article published in Clinical Interventions in Aging 2012:7 175–184

89 – 113

Chapter 5 A cognitive-motor intervention using a dance video game

to enhance foot placement accuracy and gait under dual

task conditions in older adults: A randomized controlled

trial (ISRCTN05350123)

Article published in BMC Geriatrics 2012, 12:74

115 – 147

Chapter 6 Assessment of the test-retest reliability of a foot placement

accuracy protocol in assisted-living older adults

Article published in Gait & Posture 38 (2013) 784–789

149 – 166

Chapter 7 General Discussion 169 – 186

Chapter 8 Summary / Zusammenfassung 189 – 213

Danksagungen

PhD curriculum

Curriculum vitae

One

General Introduction

Ch

ap

ter

6

Chapter One

The improvement of physical functioning and the prevention of falls in the older population

have been of great interest since the 1980‘s [1-3]. ‘Physical functioning‘ refers to the ability to

conduct a variety of activities ranging from self-care (instrumental activities of daily living)

to more challenging mobility tasks that require balance abilities, strength or endurance, e. g.

walking or standing, important for achieving or maintaining an independent way of living [4,5].

A fall is defined as a situation in which a person unintentionally comes to the ground

or to some lower level other than as a consequence of sustaining a violent blow, a loss

of consciousness, or a sudden onset of paralysis as in stroke or epileptic seizure [6]. The

interest in this topic lies in the fact that the decline of physical functioning and above

all the increasing incidence of falls are under the many undesirable ancillary effects of

the natural aging process and can lead as the case may be to a premature admission

to care homes, the loss of independence or even to an increasing rate of morbidity, or

mortality [7, 8].

Fall prevention is of particular importance when considering the steady increase of

life expectancy of human beings. Thanks to better sanitation, higher standards of living

and a well-organized and efficient health care system, life expectancy has nearly doubled

during the last century. In Switzerland, for instance, from 1900 to 2011 life expectancy

increased from 49 to about 85 years in women and from 46 to about 80 years in men [9].

It has been observed that approximately one third of the population over 65 years of age

statistically experience a fall each year. The incidence of falls even increases to 50% in

people aged 85 and over [8,10]. Falls are by now the leading cause of hospitalization

related to injuries in older adults. The major injuries that result from a fall are, besides soft

tissues injuries, serious fractures of the wrist, the elbow, the trunk, the head and the

hips [11,12]. Fear of falling is a common reported concern in older adults, especially in

individuals who have already experienced a fall, and can lead to a further decrease in

activity of daily life, a further decline in physical functioning and to a general decrease in

quality of life [13, 14].

7


1.1. Causes of a fall

The causes of a fall are still in dispute. The increased incidence of falls has long been

attributed to the decline of physical abilities, reduced sensory functions, and to the

slowdown of psychomotor processing, all being common consequences of the natural

aging process [15–17]. The decline in muscle mass and strength is a natural process of

aging which already begins at the young age of 30. Muscle mass declines by 10% – 15% per

decade, and even accelerates at older ages [18, 19]. Additionally, the reduction in muscle

power (strength x velocity of movement) due to the decline in mass and contractile speed

of the skeletal muscles leads to relevant restrictions in activities of daily life [19, 20]. This

may cause slowing, and increases variability of gait patterns or gives rise to insecurities in

balance, representing a possible major cause of a fall [21–23].

The American Geriatrics Society has suggested risk factors that seem to be related

to the higher risk for falling in institutionalized or community-dwelling older adults [7].

The main proposals included factors related to poor physical functioning like muscle

weakness, gait and/or balance deficits, and associated factors like previous falls, together

with the use of assistive devices due to reduced abilities (Table 1.1). In the past these

aspects have long been regarded as the main factors for the occurrence of a fall in older

adults. Not surprisingly, to date fall prevention programs for older adults mainly focus

on improving physical functioning by conducting interventions including physical

exercise to rehabilitate muscle strength and postural balance skills. The solution of the

fall problem, however, is not that simple as it appears. The origin of a fall is more likely

to be an individual framework composed of various risk factors rather than the result

of one or two factors alone. In addition to physical and functional impairments, this

framework also includes cognitive impairments, the influence of prescribed medications

and environmental conditions [11].

1.2. The role of cognition

One particular potential risk factor for falls has been overlooked in the past, namely

the presence of cognitive impairments in older adults. Recent research suggests a link

8

Chapter One

between gait dysfunctions and cognitive impairments [4]. In fact older adults with

cognitive impairments have a higher susceptibility to falling than peers without cognitive

impairments [24]. Older adults or younger persons with neurological impairments, people

suffering from the consequences of traumatic brain injuries or a stroke event, together

with sufferers from dementia show similar impairments of walking abilities, i.e. slower gait

speed and an increased stride time variability, as well as limitations in postural balance

abilities [25,26]. Gait dysfunctions are included among the many risk factors for falls. Older

adults with slow gait velocity, gait instability, or increased step length variability have an

increased risk of falls [26].

Table 1.1 Results of univariate analysis of most common risk factors for falls identified in 16 studies that examined risk factors [7]

Risk Factor Significant/Total* Mean RR-OR# Range

Muscle weakness 10/11 4.4 1.5 – 10.3

History of falls 12/13 3.0 1.7 – 7.0

Gait deficit 10/12 2.9 1.3 – 5.6

Balance deficit 8/11 2.9 1.6 – 5.4

Use assistive device 8/8 2.6 1.2 – 4.6

Visual deficit 6/12 2.5 1.6 – 3.5

Arthritis 3/7 2.4 1.9 – 2.9

Impaired ADL 8/9 2.3 1.5 – 3.1

Depression 3/6 2.2 1.7 – 2.5

Cognitive impairment 4/11 1.8 1.0 – 2.3

Age > 80 years 5/8 1.7 1.1 – 2.5

* Number of studies with significant odds ratio or relative risk ratio in univariate analysis/total number of studies that included each factor; # Relative risk ratios (RR) calculated for prospective studies, odds ratios (OR) calculated for retros-pective studies; ADL = activities of daily living.

Until recently gait has been assumed to be an automated task without the need for

higher-level cognitive inputs. This holds true for younger or middle-aged individuals.

Walking is a complex cognitive task [27]. The impact of cognitive functions on gait in

the older population, however, can be easily observed in every day situations. Older

adults tend to stop walking while talking [28,29] or seem to walk around with blinders

on, focusing their attention on their walking path, blocking out what is going on around

9


themselves, e.g. other pedestrians or the traffic. This observation is explained by the

assumption that cognitive resources intended for regulating the gait cycle come into

conflict with cognitive resources needed to hold a conversation or to register the changing

environmental conditions. One of the tasks will automatically be preferred to the other.

So they either stop walking and hold the conversation or observe their surroundings, or

conversely they stop talking or stop observing in order to continue on their walk. This

phenomenon has been consistently observed throughout many studies and the poorer

performance of older adults in dual task conditions is one of the most typical symptoms

of the natural aging process [30].

The impact of cognitive deficiencies on gait or postural balance is extensively

underpinned by a very substantial number of studies investigating the abilities of

older adults to manage a situation in which they are told to perform a motor task

while simultaneously executing a cognitive task [31]. This situation is referred as a dual

task situation. For instance, we can observe slowing of gait speed and/or an increased

variability of gait patterns like stride time, step length, or step width when older adults are

told to execute a cognitive task like calculating backwards from a number in steps of seven

or list words with a specific initial letter [15,32–34]. In addition, increasing reaction times

were observed in stepping responses when older adults are challenged by simultaneous

cognitive tasks [35]. Walking on the street is nothing else then a typical dual task situation

that we encounter almost every day. Hence, it is not surprising that the most frequent

causes for a fall are tripping, slipping or misplacing steps whilst walking without any

hazardous behavior even on level surfaces [36–38]. It has been observed that older adults

are at particular risk to experience a fall while they walk in busy environments [15,39].

1.3. The special role of executive functions

A challenging problem related to falls is that they can potentially occur in different

situations during daily activities and, unfortunately, in most of cases without any notice.

They can occur while standing motionless, during the phase of gait initiation or during

walking itself, even on level surfaces. Our body is constantly challenged by different

10

Chapter One

internal influences (muscle weakness, illness, fatigue, mood, cognitive impairments, vision

problems) as well as by external ones (obstacles, crowds, traffic, weather) all of which

constitute a potential threat to postural stability. These circumstances demand intact

cognitive functions to register potential threatening situations at an early stage, to plan

and execute the correct motor answer to the special condition in order to prevent a trip

or a fall. In recent fall prevention research the decline of cognitive functions that regulate

these abilities has been suggested as a major cause of falls in addition to the decline of

physical functioning [40,41]. In fact, impaired cognitive functions that regulate these

skills may negatively affect the ability to plan and react to changing demands, possibly

increasing fall risk [26].

The ability to counteract these threats is regulated by specific cognitive functions

called executive functions. ‘Executive functions‘ is an umbrella term for higher-level

cognitive functions involved in the control, the regulation, and the management of lower-

level cognitive processes, such as planning, working memory, problem solving, initiation,

inhibition, mental flexibility, task switching, and attention [42]. There is still a heated

debate on the brain structures responsible for the regulation of the theses functions.

The frontal lobes have long been assumed to be the only brain structures responsible

for executive functions [43]. Increasing evidence, however, suggests that multiple brain

areas forming a specific network are involved in cognitive processes as complex as the

executive functions [42, 44]. It has been observed that older adults perform more poorly

than younger adults on many classic neuropsychological tests of executive function (e.g.

the Color-Word Stroop task or the Trail-Making test A & B) [45]. This suggests that natural

aging is associated with a decline of executive functions [46–48].

Neuropsychological studies have observed activation in the prefrontal cortex, the

anterior part of the frontal lobes, during dual task conditions but not under single task

situations [49, 50]. Further, even age-specific activation of prefrontal cortex in response

to a dual task challenge has been observed. In a study by Ohsugi et al. [51] young and

older adults performed a single motor task (stepping), a single cognitive task (performing

calculations) or a dual task, that was the performance of the motor and cognitive task

11


simultaneously. Both younger and older adults demonstrated an increased prefrontal

cortex activity during the dual task activity, though higher and longer activation of the

prefrontal cortex was observed in the older group. These results suggest that dual task

activity imposes a greater cognitive load on older adults compared to younger.

The observation that older adults show poorer performances in dual task situations

compared to younger adults, and that this may be in part attributable to the declines in

executive functions [40] led to the assumption that the focus of effective fall prevention

programs should possibly be the implementation of approaches that address the cognitive

decline and the dysfunctions in cognitive processes, especially of the executive functions.

There is growing evidence that rather than isolated physical or cognitive activity, the

combination of both better supports the healthy functions of executive function, working

memory, and the ability to divide and select attention [52–55]. Therefore, older adults

should be challenged and trained by a cognitive-motor approach that is the performance

of physical training with a simultaneous challenge of cognitive functions stimulating the

required abilities to control gait and postural balance in dual task situations, as experienced

in everyday life. The assumption that older adults could benefit to a greater extent from a

cognitive-motor approach than from physical training alone is the underlying hypothesis

of the present doctoral thesis.

1.4. How it all started

The story of the present doctoral thesis began with the performance of interventional

and observational pilot studies at the Institute of Human Movement Sciences and Sport

(IBWS) of the ETH (Swiss Federal Institute of Technology) Zurich. Projects in the context of

a master‘s thesis in the field of ‘Human Movement Science and Sport‘ laid the foundations

for the development of the study questions presented in this thesis. The research group

at the IBWS of the ETH Zurich knew early on that the combination of motor and cognitive

elements and its implementation in training programs for the elderly could constitute

an approach with a great potential for improving physical functioning in the older

population. Two interventional pilot studies were performed using the combination of

12

Chapter One

motor and cognitive elements. The settings of these studies were comparable. Whereas

the control groups received a traditional physical exercise program consisting of strength

and balance exercises, the cognitive-motor groups performed either a computer-

based training program that focused on selective and divided attention skills [56] or a

computerized dancing game in addition [57]. The results showed excellent rates of training

adherence and high levels of enjoyment among the participants. More significantly, in the

cognitive-motor groups compared to the control groups the interventions were observed

to produce greater reductions in the fear of falling, and stronger improvements in walking

abilities (i.e. decreased dual task costs of walking) or shortened foot reaction times. These

observations instigated the further development of the cognitive-motor approach and

finally the realization of this doctoral thesis.

1.5. The aims of this doctoral thesis

This doctoral thesis discusses approaches that require consideration with a view

to including a stimulating cognitive factor in fall prevention programs. Therefore it

investigates the current state of research into using cognitive elements in fall prevention

and collects data on interventions with the aim of improving physical functioning in

older adults. Further, in its experimental section this doctoral thesis presents a novel

training approach that combines traditional physical exercise, i.e. progressive strength

and balance exercise, with an interactive dance computer game as the cognitive factor,

especially adapted to the needs of older adults. The game as cognitive-motor element

simulates a dual task situation thus stimulating the ability to comprehend, plan, adapt

and execute specific movements, properties attributed to the executive function system.

The aim of the experiments was primarily to investigate if a cognitive-motor approach

with an additional attention-demanding dance computer game is feasible and accepted

by older adults. Additionally, the experiments examined if such an approach is better

suited to improving physical abilities related to gait, i.e. walking abilities and gait

initiation under dual task conditions, or the accuracy of foot placement during walking

compared to the usual care offered in senior hostels or through physical exercise alone.

13


The objective of the cognitive-motor element was to develop a training method that can

be easily performed in any senior hostel without the need of a laboratory setting or any

complicated or expensive technical equipment.

1.6. The outline of this thesis

In a first step (Chapter 2) this doctoral thesis offers some theoretical considerations based

on the findings of the previous cognitive-motor pilot studies conducted at the Institute

of Human Movement Sciences and Sport of the ETH Zurich. It is concerned with the

experiences made with computer-based approaches serving as a potential method for

the inclusion and stimulation of cognitive functions in exercise programs for older adults.

The importance and potential benefits of using virtual reality environments or interactive

video games as a novel approach to improve physical functioning in older adults under

attention-demanding circumstances are discussed and suggestions for the design of

future studies are made.

On the basis of this discussion a systematic review of literature on cognitive and

cognitive-motor interventions affecting physical functioning in older adults is presented

in Chapter 3. This review pursues the objective of examining the existing literature

regarding the use of cognitive or combined cognitive-motor interventions. The aim is to

evaluate the level of evidence for this approach in the older population, to determine the

methodological quality of the existing studies, and to identify strategies that might be

used in future intervention type studies for older adults.

Chapters 4, 5, and 6 constitute the experimental section of this doctoral thesis. These

chapters describe the application of the cognitive-motor approach in senior hostels

in the context of two randomized controlled trials performed in four senior hostels in

Switzerland. Chapter 6 constitutes a study, which investigates the test-retest reliability

of a protocol used in the experiment described in Chapter 5 to assess foot placement

accuracy during walking.

In Chapter 4 a randomized controlled pilot study is described which aims to explore

whether a cognitive-motor exercise program that combines traditional physical exercise

14

Chapter One

with a dance computer game is better suited to improve the voluntary stepping responses

of older adults under attention-demanding dual task conditions. Residents of two senior

hostels of the city of Zurich perform either twice-weekly cognitive-motor exercise for 12

weeks (n = 9) or continue with the usual care offered at their hostels (n = 6). As the main

outcome, a measure voluntary step execution under single and dual task conditions is

recorded at baseline and post intervention.

Chapter 5 describes a randomized controlled trial performed in two senior hostels in

the Canton of Zurich with the aim to compare two training groups that achieve similar

amounts of strength and balance exercise where one group receives an intervention

that includes additional computer game dancing. The dance group (n = 15) absolves a

twelve-week cognitive-motor exercise program twice weekly that comprises progressive

strength and balance training supplemented with additional computer game dancing.

The control group (n = 16) performs only the strength and balance exercises during

this period. Main outcome measures are foot placement accuracy performance during

walking, gait performance under dual task conditions, and falls efficacy.

In Chapter 6 this doctoral thesis offers the results of an experiment to analyze the test-

retest reliability of the protocol used to assess foot placement accuracy performance in the

context of the randomized controlled trial presented in Chapter 5. One observer assesses

twenty-five elderly subjects in two sessions with 48 hours as time interval between the

measurements. The main outcome measures are foot placement distance errors, intraclass

correlation coefficients (ICC), and the smallest detectable difference value (SDD).

This doctoral thesis concludes with a general discussion where the main results,

methodological issues, clinical implications, suggestions for future work, and the

conclusions are outlined (Chapter 7). Finally, a short summary of the doctoral thesis in

English and German is provided in Chapter 8.

15


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55. Silsupadol P, Shumway-Cook A, Lugade V, van Donkelaar P, Chou LS, Mayr U, Woollacott

MH: Effects of single-task versus dual-task training on balance performance in older

adults: a double-blind, randomized controlled trial. Arch Phys Med Rehabil 2009,

90(3):381-387.

56. de Bruin ED, van Het Reve E, Murer K: A randomized controlled pilot study

assessing the feasibility of combined motor-cognitive training and its effect on gait

characteristics in the elderly. Clin Rehabil 2013, 27(3):215-225.

57. de Bruin ED, Reith A, Dörflinger M, Murer K: Feasibility of Strength-Balance Training

Extended with Computer Game Dancing in Older People; Does it Affect Dual

20

Chapter One

Task Costs of Walking? J Nov Physiother 2011, 1(104): Accessible at http://www.

omicsgroup.org/journals/2165-7025/2165-7025-2161-2104.php?aid=3350.

21


Two

Use of virtual reality technique for the training of motor control in the elderly:

some theoretical considerationsde Bruin ED1, Schoene D2, Pichierri G1 and Smith ST2

1Institute of Human Movement Sciences and Sport, ETH Zurich, Switzerland

2Neuroscience Research Australia, Sydney

published in Z Gerontol Geriat 2010, 43:229–234C

ha

pte

r

24

Chapter Two

Abstract

Virtual augmented exercise, an emerging technology that can help to promote physical

activity and combine the strengths of indoor and outdoor exercise, has recently been

proposed as having the potential to increase exercise behavior in older adults. By creating

a strong presence in a virtual, interactive environment, distraction can be taken to greater

levels while maintaining the benefits of indoor exercises which may result in a shift from

negative to positive thoughts about exercise. Recent findings on young participants show

that virtual reality training enhances mood, thus, increasing enjoyment and energy.

For older adults virtual, interactive environments can influence postural control and

fall events by stimulating the sensory cues that are responsible in maintaining balance

and orientation. However, the potential of virtual reality training has yet to be explored

for older adults. This manuscript describes the potential of dance pad training protocols

in the elderly and reports on the theoretical rationale of combining physical game-like

exercises with sensory and cognitive challenges in a virtual environment.

Keywords: geriatric adults, virtual reality, virtual environment, physical activity, indoor

exercise

25

Use of virtual reality technique

2.1. Background

Decline in physical function is a common feature of older age and has important

outcomes in terms of physical health related quality of life, falls, health care use,

admission to residential care and mortality [1, 2]. The most common reason for loss in

functional capabilities in the aged, however, is inactivity or immobility [3–5]. Even in

the absence of overt pathology, motor functioning [cf. International Classification of

Functioning (ICF) by the World Health Organization, Geneva (see http://www.who.int/

classification/icf) can deteriorate, as is illustrated by the incidence and impact of falls

in ageing populations [6]. Falls are amongst the most common reasons for medical

intervention in the elderly and their occurrence might initiate a vicious circle that causes

fear of falling, nursing home admittance and loss of independence [7]. Falls among older

adult populations often occur during walking, and gait dysfunction is included among

the many risk factors for falls [8, 9].

Until recently, gait was considered an automated motor activity requiring minimal

higher-level cognitive input [10]. Maintenance of postural control during activities of

daily living does not usually place high demands on attention resources of healthy young

or middle-aged people. In contrast however, when sensory or motor deficits occur due

to natural ageing processes, the complex generation of movement may have to be

restructured, and movements may then be controlled and performed at an associative

or a cognitive stage [11]. When the benefits from the movement automation are lost,

the postural control of aged people can be expected to be more vulnerable to cognitive

distractions and additional tasks [11]. The link between cognition, gait, and the potential

for falls is indeed being increasingly recognized [12] and is for example reflected in a

special issue in the Journal of Gerontology: Biological Sciences and Medical Sciences (63A

(12), 2008).

Negative plastic changes in the brain often occur naturally in later life when people begin

to stereotype and simplify behaviors that previously were quite complex and elaborated.

As people age, a self-reinforcing, downwards spiral of reduced interaction with challenging

environments and reduced brain health significantly contribute to this cognitive decline [13].

26

Chapter Two

2.2. Physical exercise to restore postural balance and walking function

Because difficulties of walking are a key factor in loss of independence for older

individuals [14, 15] treatment of gait disorders is designed to optimize gait for the

purpose of improving function. Previous studies have shown that physical exercise is

effective [16] and may reduce gait variability in elderly [17]. Current evidence shows that

interventions that aim to improve locomotor function in older people should preferably

include strength training in combination with balance and coordination exercises [16,

18]. However, common interventions usually focus on the physical aspects of training

while overlooking the specific rehabilitation of executive functions [19], a set of cognitive

abilities that control and regulate other abilities and behaviors.

A central element of successful cognitive rehabilitation for older adults should be the

design of interventions that either re-activate disused or damaged brain regions, or that

compensates for decline in parts of the brain through the activation of compensatory

neural reserves [20]. Cognitive activity or stimulation could be a protective factor against

the functional losses in old age. Because spatial and temporal characteristics of gait are

also associated with distinct brain networks in older adults it can be hypothesized that

addressing focal neuronal losses in these networks may represent an important strategy

to prevent mobility disability [21]. Interventions should, as previous research suggests,

focus thereby on executive functioning processes [22] and should include enriched

environments that provide physical activities with decision-making opportunities because

these are believed to be able to facilitate the development of both motor performance

and brain functions [23]. Executive cognitive functions are involved in the control and

direction (planning, monitoring, activating, switching, inhibiting) of lower level, more

modular, or automatic functions [24].

2.3. Virtual augmented exercises

Involvement of real-time simulation in an environment, scenario or activity that allows

for user interaction via multiple sensory channels as an approach to user–computer

interface can be defined as virtual reality [25]. Virtual reality (VR) system complexity

27


ranges from cheap, readily available video gaming consoles such as the Nintendo Wii,

Sony Playstation or Microsoft Xbox, through to dedicated, high costs systems such as the

GestureTek IREX. The less complex and cheaper systems that require physical movement

by the game player sometimes are referred to as exergames. VR techniques are rapidly

expanding across a variety of disciplines. The use of virtual reality environments for virtual

augmented exercise has recently been proposed as having the potential to increase

exercise behavior in older adults [26] and also has the potential to influence cognitive

abilities in this population segment [27]. The potential is based on strong presence (the

feeling of being there) which is achievable in an interactive virtual environment and that

is followed by greater distraction. Weiss and colleagues [28] suggest that virtual reality

platforms provide a number of unique advantages over conventional therapy in trying to

achieve rehabilitation goals.

First, virtual reality systems provide ecologically valid scenarios that elicit naturalistic

movement and behaviors in a safe environment that can be shaped and graded in

accordance to the needs and level of ability of the patient engaging in therapy. Second,

the realism of the virtual environments allows patients the opportunity to explore

independently, increasing their sense of autonomy and independence in directing their

own therapeutic experience. Third, the controllability of virtual environments allows for

consistency in the way therapeutic protocols are delivered and performance recorded,

enabling an accurate comparison of a patient’s performance over time. Finally, virtual

reality systems allow the introduction of „gaming“ factors into any scenario to enhance

motivation and increase user participation [29].

The use of gaming elements can also be used to take patients’ attention away from

any pain resulting from their injury or movement. This occurs the more a patient feels

involved in an activity and again, allows a higher level of participation in the activity, as

the patient is focused on achieving goals within the game [30]. In combination with the

benefits of indoor exercises such as safety or independence from weather conditions,

such a distraction may result in a shift from negative to positive thoughts about exercise.

Many different forms of equipment can be used in order to create different kinds of

28

Chapter Two

virtual environments. The basic components of all forms are a computer, usually with

a special graphics card for the fast computation and drawing of two- (2D) or three-

dimensional (3D) visual images, display devices through which the user views the virtual

environment, hardware devices used to monitor movement kinematics or that provide

haptic and force feedback to participants, and especially written software that enables all

of these components to work in synchrony [31]. There are both more immersive 3D and

less immersive 2D virtual environments. The latter are more kindred to looking through

a window at a scene. Immersion refers to the establishment of the feeling of being inside

and a part of the VR world.

2.4. VR and exergames as motor rehabilitation training

Although VR applications have been used in research and entertainment applications

since the 1980s, it was only during the late 1990s that VR systems began to be developed

and studied as potential tools to enhance and encourage participation in rehabilitation.

Several studies have since emerged suggesting the potential of virtual reality as a successful

treatment and assessment tool in a wide variety of applications, most notably in the fields

of motor and cognitive rehabilitation. In young subjects, it has already been shown that

exercising on a stationary bike combined with a virtual cycling race enhances enjoyment

and reduces tiredness [32], and promotes gains in cognitive function in brain-injured

individuals [33]. For older adults interactive virtual environments can influence postural

control and therefore fall events by stimulating the sensory cues that are responsible in

maintaining balance and orientation [34].

Exergaming interventions (dance pad stepping, Wii balance board) improved

parameters of static balance more than a traditional balance program in young healthy

adults after 4 weeks of training [35]. Merians and colleagues [36] found that exercise

conducted using a virtual reality interface enhanced the training of hand movements

in patients post stroke, resulting in improved function of the fingers, thumb, and overall

range of motion. These researchers also found that an improvement later transferred to

real world tasks, demonstrating that VR-based therapy has the potential to encourage

29


a level of exercise intensity and participation that is comparable to conventional

interventions [36]. The special value of VR training paradigms is believed to be due to

the concordance of visual and proprioceptive information during training, thus updating

the way seniors perceive their body with their environment [37]. Beside this stimulation,

virtual environments provide salient feedback about the movement performance,

and the difficulty of the task can be adapted according to the subject’s ability, which is

particularly important for older adults. Virtual environments have also the potential to

specifically include motor learning enhancing features that activate motor areas in the

brain [38]. In addition the findings of You and colleagues suggest that VR training could

induce reorganization of the sensorimotor cortex in chronic stroke patients [39]. However,

the potential of such virtual reality trainings has yet to be explored for older adults.

In the following, to cite an example, we describe a low cost video game-based approach

to training and rehabilitation of stepping ability that can potentially be used to reduce the

risk of falls in older adults or for rehabilitation of balance control in stroke, spinal cord

injury or other motor-impaired patients. We describe the theoretical considerations that

indicate the potential of this technology for elderly together with some preliminary results

from our research groups.

2.5. Exergame use for motor control training in the elderly

Interactive, user input devices such as dance pads are a low cost, interactive method of

exergaming. These games, e.g. “Dance Dance Revolution” (DDR) or “Pump” are played on

a dance pad sensor, which measures about 1 m2 and has between four and eight step

panels (arrows). The pad is connected to a visual display screen such as a television or

computer screen that provides step direction instructions to the player via a system of

scrolling arrows that typically rise slowly from the bottom to the top of the screen. As

the arrows scroll up to the top of the screen, they cross over a set of four corresponding

arrow silhouettes. The player must step on the corresponding mat arrow as the scrolling

arrow crosses its silhouette (Figure 2.1). Sequences of steps can range in difficulty from

simple marching or walking patterns to those with varied rates and irregular patterns that

30

Chapter Two

challenge coordination and attention. It has been suggested that feed-forward planning

of gait and posture is diminished in older adults. Motor adaptation is one mechanism by

which feed-forward commands can be updated or fine-tuned [40].

The ability to make timely, appropriately directed steps underpins our ability to maintain

our balance and move unaided through our environment [41]. Stepping, which involves

changing the base of support (BOS) relative to our center of mass (COM), also provides

the means by which we are able to counter potentially destabilizing events such as slips,

trips and missteps and avoid obstacles. Protective stepping may be initiated volitionally

when a threat to balance is perceived, or induced reflexively when a disturbance moves

the COM relative to the BOS at a speed that prevents engagement of volitional strategies.

Initial studies suggest that both volitional and induced stepping abilities are significantly

impaired in older versus younger individuals and are good predictors of falls. Compared to

younger adults, older adults, particularly those with a history of falling, tend to be slower

in initiating volitional step responses [42], make inappropriately directed or multiple

short steps in response to an external perturbation of balance [43] and in response to

lateral perturbations have an increased chance of collision between the swing and

stance legs during compensatory stepping [44]. There is evidence, however, to suggest

that the timing of volitional stepping [45, 46], as well as the execution of successful steps

for recovery of balance following an induced slip [47], can be significantly improved in

older adults following repetitive training of stepping responses. Maki and colleagues [48]

have recently suggested a protocol for step training which specifically targets the kinds

of stepping abilities that contribute to falls such as collisions between legs during lateral

perturbation or the tendency for older adults to take multiple, short laterally directed steps

in response to an anterior-posterior perturbation. Although the training techniques they

suggest are well suited to specifically train compensatory stepping ability their approach

requires use of large devices (custom motion platforms [48], treadmills [47, 49], systems

employing weights and pulleys [46], low resistance slip platforms) or the supervision

of trained therapists [45]. None of these techniques could be easily or economically

incorporated into home-based training programs. Dance pad games require the player to

31


make rapid step responses from either leg to a target location in response to a presented

visual stimulus. They not only involve controlled body weight transfers that are similar

to the step responses required to avoid many falls as well as requiring a narrow base of

support and well-coordinated quick movements. They further require cognitive work,

e.g. sensing of stimuli, paying attention and making quick decisions. This interaction

of sensory, information processing and neuromuscular systems is similar to the step

responses required to avoid many falls and is therefore suitable as an intervention in a

fall-specific context (Figure 2.2).

One hurdle facing the successful use of such exercise video games (or exergames) in

older adult and functionally impaired populations is that many off-the-shelf video games

are too complex for use by these groups. Video games must therefore be developed to

take into consideration the cognitive and physical limitations, as well as the interest sets,

of older adults. In the following we discuss the ways in which research groups in general

could address these issues and in which our respective research teams are presently

involved.

Figure 2.1: Training set-up for the dance pad game. The core game play involves the player moving his or her feet to a set pattern, stepping in time to the general rhythm or beat of a song. During normal game play, arrows scroll upwards from the bottom of the screen and pass over a set of stationary arrows near the top (upper red circle) referred to as the “guide arrows” or “receptors”. When the scrolling arrows overlap the stationary ones, the player must step on the corresponding arrows on the dance platform (lower red circle), and the player is given a judgement for their accuracy (Marvelous, Perfect, Great, Good, Boo/Almost, Miss/Boo) [51].

32

Chapter Two

PerceptionAction planExecution

Falls Dance pad stepping

2.6. The use of DDR to date

The Sydney-based research group at Neuroscience Research Australia (DS & STS) has

recently begun a research program aimed at developing age-appropriate DDR (Dance

Dance Revolution)-style video games. The aim of this group is to both engage older adults

in home-based step training exercises to reduce their falls rate as well as monitoring fall

risk. In particular they aim to develop a low-cost approach to engage older adults in fall

prevention training that can be placed into the houses of individuals, many of them

living in regional, remote parts of Australia. A recently published paper [50] describes a

series of studies conducted to develop and establish characteristics of DDR videogame

play in older adults. Participants aged 70 and above were asked to make simple step

movements in response to vertically drifting arrows presented on a video screen. Step

responses were detected by a modified USB DDR mat and characteristics of stepping

performance such as step timing, percentage of missed target steps and percentage of

correct steps, were recorded by purpose built software. Drift speed and step rate of visual

stimuli were modified to increase task difficulty. Performance of older adults decreased

as stimulus speed and step rate were increased. Optimal step performance occurred for

a stimulus speed of 17° of visual angle per second and a step rate of one step every 2

seconds. At fast drift speeds (up to 35°/second), participants were more than 200 ms too

slow in coordinating their steps with the visual stimulus. Younger adults were better able

to perform the stepping task across a wider range of drift speeds than older adults.

Data of another recently finished study from this group indicate that the dance pad

is a valid and reliable assessment instrument to measure the choice stepping reaction

Figure 2.2: Processes involved in avoiding a fall and in dance pad stepping.

33


time in old and young people, a test that has shown to be predictive for falls in the elderly

[42]. This offers the opportunity to assess the fall risk of older adults on a regular basis

from the comfort of their own home. The aim of a recently finished study in Zurich was to

assess and compare the effects of a physical training program that included a VR dance

simulation computer game against usual care exercise interventions for elderly residential

care dwellers on relative dual tasking costs of walking [51]. These costs refer to the fact

that many older adults exhibit a reduced ability to perform two tasks at the same time,

e.g. walking at preferred speed is compared to walking at preferred speed whilst counting

backwards. This study showed that elderly who were training physically, in combination

with a VR dance game that required decision making, showed significant decreases in

the relative dual task costs (DTC) of walking. These walking parameters did not change

in individuals that trained with more traditional forms of training in usual care programs.

The possibility of improving gait while performing dual tasks has not been well

studied in general [10] and, to the best of our knowledge, this study [51] is one of the

first that showed an effect on DTC-related walking. This study, which has been submitted

for publication as a full text article, used dancing in a virtual environment as dual task

training, where subjects were expected to observe the environment for drifting arrows

and at the same time were initiating dance steps (Figure 2.1).

2. 7. Conclusions

For older adults virtual, interactive environments have large potential to influence postural

control and fall events by stimulating the sensory cues that are responsible in maintaining

balance and orientation and by improving stepping patterns. However, the potential of

virtual reality training has yet to be explored in sufficiently powered randomized controlled

trials. Dance pad games, where repetitive medio-lateral and anterior-posterior steps

are required offer a novel, yet effective, technique for training stepping ability in older

adults. Future research should develop, implement and evaluate VR exercise scenarios for

various sub-populations that can be identified within the elderly adult population. In such

projects an attempt could be made to get insight into the concept of motor learning in

34

Chapter Two

VR and the relationship between cognitive functions and balance and gait skills in elderly.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

35


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39


extended with computer game dancing in older people; does it affect dual task cost

of walking?. J Nov Physiother 2011, 1(104): Accessible at http://www.omicsgroup.

org/journals/2165-7025/2165-7025-2161-2104.php?aid=3350.

Three

Cognitive and cognitive-motor interventions affecting physical

functioning: A systematic reviewPichierri G1, Wolf P2, Murer K1 and de Bruin ED1


2Department of Mechanical and Process Engineering, ETH Zurich, Switzerland

published in BMC Geriatrics 2011, 11:29 (www.biomedcentral.com/1471-2318/11/29)

Ch

ap

ter

Chapter Three

42

Abstract

Background: Several types of cognitive or combined cognitive-motor intervention types

that might influence physical functions have been proposed in the past: training of dual-

tasking abilities, and improving cognitive function through behavioral interventions or

the use of computer games. The objective of this systematic review was to examine the

literature regarding the use of cognitive and cognitive-motor interventions to improve

physical functioning in older adults or people with neurological impairments that

are similar to cognitive impairments seen in aging. The aim was to identify potentially

promising methods that might be used in future intervention type studies for older adults.

Methods: A systematic search was conducted for the Medline/Premedline, PsycINFO,

CINAHL and EMBASE databases. The search was focused on older adults over the age of

65. To increase the number of articles for review, we also included those discussing adult

patients with neurological impairments due to trauma, as these cognitive impairments

are similar to those seen in the aging population. The search was restricted to English,

German and French language literature without any limitation of publication date or

restriction by study design. Cognitive or cognitive-motor interventions were defined as

dual-tasking, virtual reality exercise, cognitive exercise, or a combination of these.

Results: 28 articles met our inclusion criteria. Three articles used an isolated cognitive

rehabilitation intervention, seven articles used a dual task intervention and 19 applied a

computerized intervention. There is evidence to suggest that cognitive or cognitive-motor

methods positively affect physical functioning, such as postural control, walking abilities

and general functions of the upper and lower extremities, respectively. The majority of the

included studies resulted in improvements of the assessed functional outcome measures.

Conclusions: The current evidence on the effectiveness of cognitive or cognitive-motor

interventions to improve physical functioning in older adults or people with neurological

impairments is limited. The heterogeneity of the studies published so far does not

Cognitive and cognitive-motor interventions

43

allow defining the training methodology with the greatest effectiveness. This review

nevertheless provides important foundational information in order to encourage further

development of novel cognitive or cognitive-motor interventions, preferably with a

randomized control design. Future research that aims to examine the relation between

improvements in cognitive skills and the translation to better performance on selected

physical tasks should explicitly take the relation between the cognitive and physical skills

into account.

3.1. Background

Age-related deteriorations in physical functioning have been attributed to decreases in

sensory or motor system function [1]. 'Physical functioning' refers to the ability to conduct

a variety of activities ranging from self-care (instrumental activities of daily living) to

more challenging mobility tasks that require balance abilities, strength or endurance,

e.g. walking or standing, important for achieving or maintaining an independent way of

living [2,3]. Until recently, for example, gait was considered an automated motor activity

requiring minimal higher-level cognitive input [4]. Therefore, it seemed only logical that

prevention of falls was mainly focused on exercises that address the modifiable physical

aspects of fall related mobility impairments, e.g. strength and balance training [5–7].

Consistent evidence has been accumulated that regular physical training can improve

muscle strength, aerobic capacity and balance, and delay the point in time when older

adults need assistance to manage activities of daily living [5]. Maintenance of postural

control during activities of daily living does not usually place high demands on attentional

resources of healthy young or middle-aged people. In contrast, when sensory or motor

deficits occur due to the natural aging process, the complex generation of movement may

have to be adjusted. Movements may then be controlled and performed at an associative

or a cognitive stage. Consequently, the postural control of older adults might be more

vulnerable to cognitive distractions and additional tasks [8]. Recent research indicates

that the influence of motor and sensory impairments on falls is in part moderated by the

executive functions [9] and, thus, some of the causes of gait disturbances might also be

Chapter Three

44

attributed to changes in the executive functions [4], e.g., changes in divided attention

[10,11]. 'Executive function' refers to cognitive processes that control and integrate other

cognitive activities [12,13], and this term has been used to describe a group of cognitive

actions that include: dealing with novelty, planning and implementing strategies for

performance, monitoring performance, using feedback to adjust future responding,

vigilance, and inhibiting task-irrelevant information [12] of lower level, more modular,

or automatic functions [14]. Common tasks of daily life require attention, rapid motor

planning process, and effective inhibition of irrelevant or inappropriate details. Older

adults, however, experience increasing difficulties in maintaining multiple task rules in

working memory [15].

These findings imply that in addition to physical forms of training, we should possibly

also consider cognitive rehabilitation strategies that aim to influence physical functioning,

e.g., walking behavior of older adults [16]. The question remains, however, what the best

strategies are, that can support achieving this aim.

Several types of cognitive or cognitive-motor interventions that might be able to

improve physical functioning have been proposed in the past: cognitive rehabilitation

interventions, training of dual-tasking abilities, and the use of computer games or virtual

reality [4,17].

Cognitive rehabilitation, defined by the Brain Injury Interdisciplinary Special Interest

Group (BI-ISIG) of the American Congress of Rehabilitation Medicine as a „systematic,

functionally-oriented service of therapeutic cognitive activities, based on an assessment

and understanding of the person‘s brain-behavior deficits“ [18], has shown to be effective

in clinical practice [19,20].

Cognitive rehabilitation interventions have been developed to ameliorate cognitive

problems experienced by healthy older adults [21,22], and for adults suffering from

traumatic brain injury [19,23,24], with the goal of maximizing their current cognitive

functioning and/or reducing the risk of cognitive decline. Some of the cognitive

interventions, however, also show transfer effects to physical functioning. Specific motor

imagery protocols seem to improve mobility in people with stroke [25].


45

Cognitive-motor interventions are interventions that combine a cognitive with a physical

rehabilitation task, e.g. strength and balance exercises together with cognitive exercises

or performing dual-tasking exercises. Interventions that used dual-tasking paradigms

demonstrated negative effects on postural control or gait while performing a concurrent

cognitive task in older adults [26,27], in patients with brain injury [28,29] and Alzheimer‘s

disease [30]. Several authors have suggested that procedures to improve the dual task

performance of elderly should be included in fall prevention programs [31].

Computerized interventions can be divided into biofeedback based systems or systems

that use elements of virtual reality. Becoming aware of various physiological functions

by using instruments that provide information on the activity of those same systems is

considered biofeedback training. The goal, thereby, is to be able to manipulate these

systems at will. Processes that can be controlled include for example dynamic balance

on a force platform where visual feedback gives information about the center of pressure

movements [32]. In virtual reality, in contrast to biofeedback training, environments are

created that allow users to interact with images and virtual objects that appear in the

virtual environment in real-time through multiple sensory modalities [32,33]. Playing of

computer games induced cognitive benefits in older adults [34], and is proposed as a

training strategy that may transfer to physical activity related tasks [4].

All three strategies, cognitive rehabilitation, training of dual-tasking abilities, and

computerized interventions, have mainly been applied to individuals with stroke, with

traumatic brain injury or elderly. Although it seems intuitive that these groups cannot be

compared because of the different underlying causes for their respective brain deficits,

this may not actually be the case [35,36]. Studies using a neuropsychological deficit profile

methodology suggest that the pattern and extent of cognitive decline associated with

these conditions is similar, at least partly, for both cognitive and motor deficits [36,37].

This implies that the treatment approaches needed to remediate the observed deficits are

theoretically also comparable.

The objective of this systematic review is to examine the literature regarding the

use of cognitive and cognitive-motor interventions to improve physical functioning in

Chapter Three

46

older adults and in adults with neurological impairments. The aim is to identify strategies

that have the potential to affect physical functioning and that might be used in future

intervention type studies for older adults. The specific questions that we asked were:

1. What types of cognitive and cognitive-motor intervention methods have been

used to influence physical functioning of older adults or adults with neurological

impairments?

2. What is the level of evidence for cognitive and cognitive-motor interventions to

influence physical functioning in these populations?

3. What is the methodological quality of these studies?

The underlying assumption that drives these questions is that (changes in) cognition also

has an impact on physical functioning.

3.2. Methods

3.2.1. Data sources and search strategies

In a first step we undertook a scoping review to gain an overview about existing

interventions or systematic reviews on this topic. In addition to studies conducted with

older adults, interventions with traumatic brain injury patients and patients with stroke

were found. Like older adults, people with brain injury or stroke show difficulties with

postural balance, exhibit gait insecurities when performing dual tasks and have cognitive

deficits evident in working memory, attention, and information processing [35,38].

Additionally it has been shown that people with brain injuries show similar characteristics

as older adults with an advanced aged-related cognitive decline. The patterns of cognitive

decline observed in patients after traumatic brain injury resembles that of classic aging

processes [35,39,40].

The search strategy was focused on older adults over the age of sixty-five. Although

we are aware that cognitive and physical deficits in patients with brain injury are not fully

comparable with the natural aging process we additionally searched further studies with

brain injured patients. We also decided to include studies conducted with stroke patients

arising from our search, because of their methodological importance for this review and


47

the possible applicability of the applied methods in the general older population.

We developed an individualized electronic search strategy for the Medline/Premedline,

PsycINFO, CINAHL, and EMBASE databases in collaboration with a librarian from the

Medicinal Library of the University of Zurich. The search was restricted to English, German,

and French language literature. There was no limitation of publication date or restriction

by study design. The final search was performed in July 2010.

Table 3.1 Search strategy

Area Search terms

Population (aging or aged or elder*); exp Aged; exp Brain Injuries((injur* or trauma*) adj2 (brain or head or craniocerebral))

Outcomes/ Physical aspect ((quantify* or measure* or assess* or investigat* or examin* or evaluat*) adj5 (gait or walk* or balance or movement or mobility or posture or “motor function” or “physical functioning” or frailty)(balance adj3 (training or impair* or effect*))postural balance, gait, walking; Accidental Falls [Prevention and Control]equilibrium, postur*

Intervention (strateg* adj3 (training or learning or cognit* or metacognit*))((cognit* or metacognit*) adj3 (intervention or rehabilitation or task or strateg* or therap*)); (goal adj1 (setting or planning or attain* or achiev* or direct* or orient* or manag*)); (self adj3 (talk or evaluat*))(self adj3 (awareness or monitoring or control or instruction or regulation))(“executive functions” or metacognition or awareness or “problem solving” or metamemory or attention); biofeedback, user-computer interface(action game* or virtual reality or video game*); (computerized adj10 training); (computer* adj10 biofeedback); ((cognitive or dual) adj5 task“self-directed learning”, “task performance”, mental imager*

We used medical sub-headings as search terms, including the following main terms

for the population: aged, elder, old, aging, brain/head/craniocerebral injury, trauma; for

cognitive aspects: cognition, meta-cognition, learning, awareness, attention, self-directed

learning, executive function; for motor functions: gait, walking, balance, movement, mobility,

posture, motor function, accidental falls, training, exercise, physical functioning and for the

interventions of interest: cognitive therapy/rehabilitation/intervention, problem solving,

biofeedback, virtual reality, video game, action game, computerized training, user-computer

interface, dual task (Table 3.1). The search strategy was initially run in Medline/Premedline

Chapter Three

48

and then adapted to the search format requirements of the other databases included in

this review. The search results were supplemented by articles found through hand search

by scanning reference lists of identified studies.

3.2.2. Study collection

After duplicate citations were removed, two reviewers (GP, EDdB) determined which

articles should be included within the systematic review by scanning the titles, abstracts

and keywords applying the inclusion and exclusion criteria (Table 3.2). A study was

considered eligible for inclusion in the review when it was examining the results of a

cognitive or cognitive-motor intervention on physical functioning of older adults.

As mentioned in the introduction, we included any study that arose from our search

concerning people with traumatic brain injury or stroke patients. Cognitive and cognitive-

motor interventions were considered studies that included cognitive rehabilitation or a

combination of cognitive rehabilitation and physical exercise, respectively. We did not

include studies that solely carried out single tests without an intervention. We adopted

the definition of the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the

American Congress of Rehabilitation Medicine for cognitive rehabilitation to guide our

search. Studies evaluating the effectiveness of pharmacological therapy were excluded.

If title, abstract or key words provided insufficient information for a decision on inclusion,

the methods section of the full-text article was considered.

3.2.3. Data extraction and data synthesis

The following data were extracted from the studies: (1) characteristics of the studied

population: number of participants, disease and age, (2) characteristics of the interventions:

the design, frequency and duration of the intervention, co-interventions, and control

intervention; (3) characteristics of the outcomes: outcome measures and results (Tables

3.3 and 3.4).

The included studies were divided into three groups: a) cognitive rehabilitation, b)

dual task interventions and c) computerized interventions. Computerized interventions


49

included every study using an electronic game or task that involves interaction with a

user interface to generate visual feedback on a display device. Because we expected the

interventions and reported outcome measures to be markedly varied, we focused on a

description of the studies and their results, and on qualitative synthesis rather than meta-

analysis.

Table 3.2 List of inclusion and exclusion details

Area Inclusion details

PopulationAny elderly subjects over 65 years, adult (aged > 18 years) brain trauma patients, studies with stroke patients

Study type Intervention studies of any type, including case studies and non-randomized trials

InterventionCognitive or cognitive-motor rehabilitation intervention (physical exercise must include a cognitive aspect)

Outcomes Outcomes focus on general physical functioning and mobility of upper or lower extremities

Exclusion details

Purely physical training, interventions without training period (tests), dual task intervention without concurrent cognitive task, animal studies, reviews, methodological, theoretical or discussion papers, studies that examine the effect of physical exercise on cognition.

3.2.4. Assessment of study quality

As the basis for our critical appraisal of the studies, a checklist designed for assessing the

methodological quality of both randomized and non-randomized studies of healthcare

interventions developed by Downs and Black [41] was used. The checklist assesses biases

related to reporting, external validity, internal validity, and power. Seven items concerning

follow-up analyses (items 9, 17 and 26), allocation concealment (items 14 and 24), adverse

effects (item 8), and representativeness of treatment places and facilities (item 13) were

not considered in this review. The items were excluded because we were not primarily

interested in possible long-term effects of cognitive or cognitive-motor interventions but

rather in short-term effects of the interventions on motor functioning.

Chapter Three

50

Table 3.3 Included studies reported by design and subject specifications

Study Design n Subjects Age: range or mean [years]

Cognitive Rehabilitation Interventions

Batson et al 2006 RCT 6 Community dwelling older adults 65–80

Dunsky et al 2008 Non-RCT 17 Community dwelling adults with hemiparetic stroke 44–79

Hamel & Lajoie 2005 RCT 20 Older adults 65–90

Dual task Interventions

Shigematsu et al 2008 RCT 63 Community dwelling older adults 65–74

Shigematsu et al 2008 RCT 39 Community dwelling healthy adults 65–74

Silsupadol et al 2006 Case study 3 Older adults with history of falls 82, 90 and 93

Silsupadol et al 2009 RCT 21 Older adults 75.0 ± 6.1

Vaillant et al 2006 RCT 68 Community dwelling older women with osteo-porosis

73.5 ± 1.6

You et al 2009 RCT 13 Older adults with history of falls 68.3 ± 6.5

Computerized Interventions

Bisson et al 2007 Pre-Post 24 Community dwelling older adults VR: 74.4 ± 3.65; BF: 74.4 ± 4.92

Broeren et al 2008 Pre-Post 22 Community dwelling adults with stroke 67.0 ± 12.5

Buccello-Stout et al 2008 RCT 16 Older adults 66–81

Clark et al 2009 Case study 1 Woman resident of a nursing home with unspecified balance disorders

89

de Bruin et al 2010 Two groups control

35 Older adults living in a residential care facility IG: 85.2 ± 5.5; CG: 86.8 ± 8.1

Deutsch et al 2009 Case study 2 Chronic phase post-stroke 34 and 48

Hatzitaki et al 2009 RCT 48 Community-dwelling healthy older women 70.9 ± 5.7

Hinman 2002 RCT 88 Community-dwelling older adults 63–87

Jang et al 2005 RCT 10 Patients with stroke 57.1 ± 4.5

Kerdoncuff et al 2004 RCT 25 Patients with stroke 59.5 ± 13.5

Lajoie 2003 RCT 24 Community-dwelling elderly IG: 70.3; CG: 71.4

Mumford et al 2010 Case study 3 Patients with TBI 20, 20 and 21

Sackley et al 1997 RCT 26 Patients with stroke 41–85

Srivastava et al 2009 Pre-Post 45 Patients with stroke 45.5 ± 11.2

Sugarman et al 2009 Case study 1 Patent with stroke 86

Talassi et al 2007 Case-control 54 Community-dwelling older adults with MCI or MD 42–91

Wolf et al 1997 RCT 72 Independently living older adults CBT: 77.7± 6.5; TC: 77.7±5.6;CG: 72.2.2±4.9

Yang et al 2008 RCT 20 Patients with stroke 30–74

Yong Joo et al 2010 Pre-Post 16 Rehabilitation inpatients within 3 months post-stroke

64.5 ± 9.6

Abbreviations: RCT = Randomized controlled trial; Non-RCT = Non-randomized controlled trial; TC = Tai Chi; VR = Virtual reality; BF = Biofeedback; IG = Intervention group; CG = Control group


51

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts

Resu

lts

Cogn

itive

Inte

rven

tions

•Sig

nifica

nt re

sults

for T

UG on

ly fo

r the

grou

p as

a who

le•

No si

gnifi

cant

resu

lts fo

r eith

er gr

oup o

r for

the

grou

p as a

who

le fo

r rem

aining

mea

sure

s

•Sp

atiot

empo

ral p

aram

eter

s: sig

nifica

ntim

prov

emen

ts in

mea

n gait

spee

d at b

aseli

ne an

d fo

llow-

up; s

tride

leng

th, p

aret

ic an

d non

-par

etic

step l

engt

h inc

reas

ed si

gnifi

cant

ly at

post-

inter

vent

ion•

Signifi

cant

incre

ase o

f sag

ittal

ROM

of th

epa

retic

knee

joint

•Sig

nifica

nt in

creas

e of g

ait sy

mm

etry

afte

rint

erve

ntion

•Tre

atm

ent e

ffect

size w

as m

oder

ate f

or m

ost

of th

e var

iables

•M

I-gro

up be

cam

e mor

e sta

ble af

ter t

raini

ng,

while

sway

of co

ntro

l gro

up in

creas

ed w

hen

com

pare

d to p

re-te

st•

A-P p

ostu

ral o

scilla

tion s

ignifi

cant

ly de

creas

ed in

MI-g

roup

•Sig

nifica

nt de

creas

e in r

eacti

on ti

me t

ask f

orM

I-gro

up•

No si

gnifi

cant

outco

mes

on BB

S and

ABC s

cales

Cont

rol

Healt

h edu

catio

n plus

phys

ical

prac

tice

6 wee

ks: 2

x/we

ek fo

r 50m

in

None

No in

volve

men

tin

any t

ype o

f tra

ining

Inte

rven

tion

Men

tal im

ager

y plus

phys

ical

prac

tice;

6 wee

ks: 2

x/we

ek fo

r 50m

in

Mot

or im

ager

y tra

ining

;6 w

eeks

: 3 x

/wee

k for

20m

in

Men

tal im

ager

y tra

ining

;6 w

eeks

: dail

y pra

ctice

Outc

ome m

easu

res

•St

anda

rdize

d mea

sure

s of

balan

ce, g

ait sp

eed a

nd ba

lance

co

nfide

nce

•BB

S, AB

C•

TUG

•Sp

atiot

empo

ral a

ndkin

emat

ic ga

it pa

ram

eter

sTin

etti

POMA

•FM

A•

Mod

ified

FWCI

•A-

P & M

-L po

stura

los

cillat

ions

•Re

actio

n tim

e to a

udito

rysti

muli

•BB

S•

ABC

Subj

ects

n=6;

com

mun

ity-d

wellin

g eld

erly;

age r

ange

: 65–

80 ye

ars

n=17

; com

mun

ity dw

elling

ad

ults w

ith he

mipa

retic

str

oke;

age r

ange

: 44–

79 ye

ars

n=20

; olde

r adu

lts;

age r

ange

: 65–

90 ye

ars

Stud

y

Batso

n et

al, 20

07

Duns

ky et

al,

2008

Ham

el an

d Lajo

ie,

2005

Chapter Three

52

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

Dual

task

Inte

rven

tions

•Fu

nctio

nal fi

tnes

s of lo

wer e

xtre

miti

esim

prov

ed m

ore i

n SSE

than

in W

•No

sign

ifica

ntly

lower

rate

of fa

lls pe

r trip

for

SSE c

ompa

red t

o W

•SS

E: sig

nifica

nt w

ithin-

grou

p im

prov

emen

tin

one-

leg ba

lance

•SB

: Sign

ifica

nt im

prov

emen

t of f

uncti

onal

reac

h•

Perfo

rman

ces o

n rem

aining

test

were

signifi

cant

ly be

tter f

or bo

th gr

oups

•Ba

lance

impr

oved

in al

l 3 pa

rticip

ants,

BBS,

DGI a

nd AB

C sco

res i

ncre

ased

•Tim

e to c

omple

te TU

G de

creas

ed un

der b

oth

cond

ition

s (pa

rticip

ants

who

rece

ived

DT-Tr

aining

sh

owed

mor

e im

prov

emen

t in T

UG un

der D

T th

an un

der S

T and

vice

versa

)•

Subje

ct wh

o rec

eived

DT-tr

aining

using

VP,

show

ed im

prov

emen

ts on

oth

er d

ual t

asks

tha

t we

re no

t dire

ctly t

raine

d (no

vel t

ask)

•Fo

llow-

up (2

wee

ks):

time t

o per

form

TUG

decre

ased

for a

ll sub

jects

•Fo

llow-

up (3

mon

ths):

Clini

cal m

easu

res o

fba

lance

wer

e ret

ained

; TUG

in su

bject

with

FP

furth

er im

prov

ed (9

%)

Cont

rol

Supe

rvise

d walk

ing (W

);12

wee

k: 1x

wee

k for

70m

in

Stre

ngth

and b

alanc

e tra

ining

; 12

wee

ks: 2

x/we

ek fo

r 70m

in

Single

task

balan

ce tr

aining

;4 w

eeks

: 3x/

week

for 4

5min

Inte

rven

tion

Squa

re-S

tepp

ing Ex

ercis

e (SS

E);

12 w

eeks

: 2x/

week

for 7

0min

Squa

re-S

tepp

ing Ex

ercis

e (SS

E);

12 w

eeks

: 2x/

week

for 7

0min

Dual

task

bala

nce

traini

ng w

ith

fixed

- (FP

) or v

ariab

le-pr

iority

(VP)

;4 w

eeks

: 3x/

week

for 4

5min

Outc

ome m

easu

res

•Ph

ysica

l tes

ts of

balan

ce, le

gstr

engt

h and

coor

dinat

ion•

Self-

repo

rted o

ccur

renc

e of

falls

or tr

ips•

Step

-reco

rding

with

pedo

met

ers

•Ch

air st

ands

, leg e

xten

sion

powe

r, sing

le-leg

balan

ce

with

eyes

clos

ed, fu

nctio

nal

reac

h, st

andin

g up f

rom

a lyi

ng

posit

ion, s

tepp

ing w

ith bo

th

feet,

walki

ng ar

ound

two c

ones

, 10

m-w

alk, S

it &

Reac

h

•M

edio-

later

al CO

Mdis

place

men

t und

sing

le ta

sk

(ST)

and d

ual t

ask (

DT)

•BB

S, AB

C•

DGI

•TU

G

Subj

ects

n= 63

; com

mun

ity dw

elling

old

er ad

ults;

age r

ange

: 65–

74 ye

ars

n=39

; com

mun

ity-d

wellin

g he

althy

adult

s;ag

e ran

ge: 6

5–74

year

s

n=3;

older

adult

s wi

th

self-

repo

rted h

istor

y of f

alls

or co

ncer

ns ab

out i

mpa

ired

balan

ce;

age:

82, 9

0 and

93 ye

ars

Stud

y

Shige

mat

suet

al, 2

008

Shige

mat

su

et al

, 200

8

Silsu

pado

l et

al, 2

006


53

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•Ad

ding c

ognit

ive ta

sks d

id no

t sign

ifica

ntly

alter

the e

ffects

of th

e exe

rcise

prog

ram

•2 w

eeks

follo

w-up

: Sign

ifica

nt im

prov

emen

ts fo

rall

outco

me m

easu

res i

n bot

h gro

ups;

TUG

time

impr

oved

mor

e in s

ingle

task

grou

p tha

n in d

ual

task

grou

p•

3 mon

ths f

ollow

-up:

Impr

ovem

ents

in TU

G-DT

signifi

cant

ly gr

eate

r in du

al ta

sk gr

oup t

han i

n the

sin

gle ta

sk gr

oup

Cont

rol

Single

task

balan

ce tr

aining

;4 w

eeks

: 3x/

week

for 4

5min

Phys

ical e

xerci

ses (

single

task

);6 w

eeks

: 2x/

week

Inte

rven

tion

Dual

task

balan

ce tr

aining

with

fix

ed- (

FP) o

r var

iable-

prior

ity (V

P);

4 wee

ks: 3

x/we

ek fo

r 45m

in

Phys

ical

exer

cise

while

cou

nting

, m

emor

izing

or re

citing

(dua

l tas

k);

6 wee

ks: 2

x/we

ek

Outc

ome m

easu

res

•Se

lf-se

lecte

d gait

spee

d und

ersin

gle an

d dua

l tas

k con

dition

s•

Gait

tem

pora

l-dist

ance

mea

sure

men

ts•

BBS,

ABC

•Av

erag

e ang

le of

fron

tal p

lane

COM

posit

ion an

d ank

le joi

nt

cent

er (A

JC)

•TU

G &

TUG-

DT•

One L

eg Ba

lance

(OLB

) and

OLB

with

conc

urre

nt ta

sk (O

LB-D

T)

Subj

ects

n=21

; elde

rly ad

ults;

mea

n age

: 75 ±

6.1 y

ears

n=68

; com

mun

ity-

dwell

ing ol

der w

omen

with

os

teop

oros

ism

ean a

ge: 7

3.5 ±

1.6 y

ears

Stud

y

Silsu

pado

let

al, 2

009

Vailla

nt et

al,

2006

•Al

l par

ticipa

nts i

mpr

oved

gait

spee

d und

er ST

cond

ition

s •

DT-g

roup

s walk

ed si

gnifi

cant

ly fas

ter u

nder

DTco

nditi

ons.

No si

gnifi

cant

diffe

renc

e in g

ait sp

eed

unde

r DT c

ondit

ions f

or ST

-gro

up

•Al

l par

ticipa

nts i

mpr

oved

balan

ce un

der S

Tco

nditi

ons

•AB

C Sca

le: ST

grou

p inc

reas

ed th

eir le

vel o

fco

nfide

nce m

ore t

han D

T gro

ups

•BB

S Sca

le: im

prov

emen

ts in

BBS w

ere c

ompa

rable

acro

ss tra

ining

grou

ps•

Follo

w-up

: DT-

traini

ng w

ith VP

instr

uctio

nsde

mon

strat

ed a

traini

ng eff

ect o

n DT-

gait

spee

d at

the e

nd of

the s

econ

d wee

k of t

raini

ng an

d also

afte

r 3 m

onth

s foll

ow-u

p•

All g

roup

s sho

wed a

sign

ifica

ntly

small

er A

JC-a

ngle

afte

r tra

ining

whe

n walk

ing un

der S

T-co

nditi

ons

•Un

der D

T-co

nditi

ons r

educ

tion o

f AJC

-ang

le wa

ssig

nifica

nt fo

r all g

roup

s, bu

t was

grea

ter f

or th

e VP

-gro

up th

an fo

r the

ST-g

roup

and F

P-gr

oup

•No

sign

ifica

nt eff

ects

on A

JC-a

ngle

in a n

ovel

(unt

raine

d) DT

-con

dition

for a

ll gro

ups

Chapter Three

54

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•No

sign

ifica

nt di

ffere

nce i

n the

M-L

COP o

r A-P

COP

devia

tion m

easu

res n

eithe

r in co

ntro

l nor

ex

perim

ent g

roup

•Sig

nifica

nt in

creas

e in g

ait sp

eed i

n con

trol g

roup

but n

ot in

expe

rimen

tal g

roup

Com

pute

rized

Inte

rven

tions

•M

ean C

B&M

scor

es fo

r bot

h gro

ups i

ncre

ased

signifi

cant

ly fro

m ba

selin

e to p

ost-t

raini

ng an

d re

tent

ion, n

o diff

eren

ce be

twee

n gro

ups

•St

atic

balan

ce: n

o diff

eren

ces b

etwe

en gr

oups

and n

o tra

ining

effec

t on v

ariab

ility o

f COP

dis

place

men

t; Sig

nifica

nt ta

sk eff

ect a

nd

inter

actio

n bet

ween

dire

ction

s of s

way a

nd ta

sks

•Re

actio

n tim

e: no

grou

p effe

ct; si

gnifi

cant

main

effec

t of t

ime;

reac

tion t

ime a

t bas

eline

sig

nifica

ntly

highe

r com

pare

d to p

ost-t

raini

ng an

d re

tent

ion; b

oth g

roup

s im

prov

ed th

eir re

actio

n tim

e equ

ally

•BB

T: In

creas

e in t

reat

men

t gro

up by

9%•

ABILH

AND:

No s

ignifi

cant

chan

ges i

n bot

h gro

ups

•TM

T-B:

med

ian ti

me d

ecre

ased

for c

omple

ting t

heta

sk in

both

grou

ps•

Kinem

atics

: Tim

e to c

omple

te th

e VR t

ask a

nd H

PRde

creas

ed si

gnifi

cant

ly in

treat

men

t gro

up•

Hand

traje

ctorie

s are

quali

tativ

ely m

ore r

estra

ined,

self-

cont

rolle

d, sm

ooth

er an

d les

s clut

ters

afte

r tra

ining

Cont

rol

Place

bo ve

rsion

of CG

I;6 w

eeks

: 5x/

week

for 3

0min

None

Cont

inued

parti

cipat

ion in

usua

l ph

ysica

l acti

vities

Inte

rven

tion

Cogn

itive

Gait

Inte

rven

tion (

CGI);

6 wee

ks: 5

x/we

ek fo

r 30m

in

Dyna

mic

balan

ce tr

aining

with

vis

ual b

iofee

dbac

k (BF

) or in

virtu

al re

ality

(VR)

;10

wee

ks: 2

x/we

ek fo

r 30m

in

3D co

mpu

ter g

ame p

lay w

ith

hapt

ic de

vice a

nd un

supp

orte

d up

per e

xtre

miti

es;

4 wee

ks: 3

x/we

ek fo

r 45m

in

Outc

ome m

easu

res

•Ga

it sp

eed

•A-

P & M

-L CO

P dev

iation

•St

atic

balan

ce

•Sim

ple au

ditor

y rea

ction

tim

eta

sk

•CB

&M

•M

anua

l Abil

ity m

easu

rem

ents

(BBT

and A

BILH

AND)

•Tra

il Mak

ing Te

st B

•Kin

emat

ics of

uppe

r ext

rem

ities

(veloc

ity, h

and-

path

ratio

, and

m

ore)

Subj

ects

n=13

; olde

r adu

lts w

ith

histo

ry of

falls

;m

ean a

ge: 6

8.3 ±

6.5 y

ears

n=24

; com

mun

ity dw

elling

old

er ad

ults;

mea

n age

: VR 7

4.4 ±

3.65

ye

ars,

BF 74

.4 ±

4.92

year

s

n=22

; com

mun

ity dw

elling

pe

rsons

with

stro

ke;

mea

n age

: 67 ±

12.5

year

s

Stud

y

You e

t al,

2009

Bisso

n et

al, 20

07

Broe

ren e

t al,

2008


55

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•Av

erag

e tim

e sco

res t

o com

plete

obsta

cle co

urse

and a

vera

ge pe

nalty

scor

es si

gnifi

cant

ly de

creas

ed

in ex

perim

enta

l gro

up af

ter in

terv

entio

n and

at

rete

ntion

(4 w

eeks

)

•Im

prov

emen

ts in

all ou

tcom

e mea

sure

s•

Self-

repo

rted i

mpr

ovem

ents

in ba

lance

,am

bulat

ion ab

ility a

nd co

nfide

nce

•DT

C: Sig

nifica

nt de

creas

e in D

TC of

walk

ingve

locity

and s

tride

tim

e in C

GD-g

roup

. No

signifi

cant

chan

ges i

n DTC

of ca

denc

e and

step

tim

e in b

oth g

roup

s•

ETGU

G: no

sign

ifica

nt ti

me e

ffect

in bo

th gr

oups

•FE

S-I: n

o sign

ifica

nt ti

me e

ffect

in bo

th gr

oups

•Ga

it sp

eed i

ncre

ased

for b

oth p

artic

ipant

s(re

taine

d at f

ollow

-up)

•Ga

it en

dura

nce i

ncre

ased

mod

estly

for b

oth

parti

cipan

ts•

DGI a

nd AB

C sco

res i

ncre

ased

for b

oth p

artic

ipant

s•

TUG

and T

UG-D

T tim

e dec

reas

ed fo

r bot

hpa

rticip

ants;

Cont

rol s

ubjec

t sho

wed f

urth

er

impr

ovem

ent a

t pos

t-tes

t

Cont

rol

Walk

ing st

raigh

t on a

trea

dmill

in a s

tatic

virtu

al ro

om; 4

wee

ks: 2

x/we

ek fo

r 20m

in

None

Usua

l car

e phy

sical

inter

vent

ion

(UC)

;12

wee

ks: 1

x/we

ek fo

r 30–

45m

in

Balan

ce an

d coo

rdina

tion a

ctivit

ies

in diff

eren

t con

dition

s; 4 w

eeks

: 3x/

week

for 6

0min

Inte

rven

tion

Walk

ing st

raigh

t on a

trea

dmill

in a

rota

ting v

irtua

l room

;4 w

eeks

: 2 x/

week

for 2

0min

Nint

endo

Wii B

owlin

g gam

e;2 w

eeks

: 3x/

week

for 6

0 min

Com

pute

r gam

e dan

cing (

CGD)

plus

pr

ogre

ssive

resis

tanc

e tra

ining

;12

wee

ks: 2

x/we

ek fo

r 45–

60m

in

Nint

endo

Wii S

ports

and W

ii Fit

Prog

ram

s; 4 w

eeks

: 3x/

week

for 6

0min

Outc

ome m

easu

res

•Tim

e to c

omple

te an

obsta

cle co

urse

with

13 so

ft ob

stacle

s•

Num

ber o

f pen

alties

onob

stacle

cour

se

•BB

S, AB

C•

DGI

•TU

G•

MM

SE

•Ga

it te

mpo

ral-d

istan

cem

easu

rem

ents

•Du

al ta

sk co

sts of

walk

ing•

ETGU

G•

FES-

I

•Ga

it sp

eed

•Six

-minu

te w

alk te

st (m

eter

s)•

BBS,

ABC

•DG

I•

TUG

and T

GU-D

T

Subj

ects

n=16

; olde

r adu

lts;

age r

ange

: 66–

81 ye

ars

n=1;

wom

an re

siden

t of

a nu

rsing

hom

e with

un

spec

ified

balan

ce di

sord

ers;

age:

89 ye

ars

n=35

; olde

r adu

lts liv

ing in

a re

siden

tial c

are f

acilit

y;m

ean a

ge: C

GD 85

.2 ±

5.5

year

s, UC

86.8

± 8.

1 yea

rs

n=2;

in ch

ronic

phas

e pos

t-str

oke p

atien

ts;ag

e: 48

and 3

4 yea

rs

Stud

y

Bucce

llo-S

tout

et

al, 2

008

Clark

et al

, 200

9

de Br

uin et

al, 20

10

Deut

sch et

al, 20

09

Chapter Three

56

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•No

rmal

quiet

stan

ce: N

o sign

ifica

nt ch

ange

s in C

OPdis

place

men

t and

angu

lar ki

nem

atics

in ei

ther

of

the t

wo tr

aining

grou

ps.

•Sig

nifica

nt eff

ect o

f tra

ining

on in

terli

mb C

OPas

ymm

etry

in A-

P gro

up•

Shar

pene

d Rom

berg

Stan

ce: S

ignifi

cant

redu

ction

of CO

P disp

lacem

ent i

n A-P

grou

p, no

adap

tatio

ns

in M

-L gr

oup.

A-P g

roup

show

ed si

gnifi

cant

ly de

creas

ed pe

ak am

plitu

de an

d SD

of lo

wer l

eg

rota

tion i

n the

pitch

dire

ction

and o

f tru

nk’s

med

io-lat

eral

rota

tion.

No s

ignifi

cant

chan

ges i

n th

e M-L

grou

p

•Su

bjects

in bo

th tr

aining

grou

ps sh

owed

sligh

tim

prov

emen

ts in

all m

easu

res.

Subje

cts of

cont

rol

grou

p im

prov

ed to

a les

ser d

egre

e

•Sig

nifica

nt di

ffere

nce b

etwe

en th

e gro

ups, V

Rgr

oup i

mpr

oved

in m

otor

func

tions

, con

trol g

roup

did

not s

how

any c

hang

e•

Corti

cal a

ctiva

tion w

as re

orga

nized

from

cont

rales

ional

to ip

siles

ional

activ

ation

in th

e lat

erali

ty in

dex

•Im

prov

emen

ts in

gait

spee

d for

cont

rol g

roup

,de

creas

e for

inte

rven

tion g

roup

•Im

prov

emen

ts in

FMA,

MFI

and B

arth

el In

dex f

orbo

th gr

oups

•Im

prov

emen

ts of

force

plat

form

para

met

ers w

ithclo

sed e

yes

Cont

rol

No in

volve

men

t in a

ny ty

pe of

tra

ining

No in

volve

men

t in a

ny ty

pe of

tra

ining

No in

volve

men

t in a

ny ty

pe of

tra

ining

Tradit

ional

traini

ng;

3 wee

ks: 5

x/we

ek

Inte

rven

tion

Balan

ce tr

aining

on pl

atfo

rm w

ith

visua

l feed

back

in A-

P or M

-L

direc

tion;

4 wee

ks: 3

x/we

ek fo

r 25m

in

Com

pute

rized

Balan

ce Tr

aining

(C

BT) o

r Hom

e pro

gram

of ba

lance

ex

ercis

es (H

EP);

4 wee

ks: 3

x/we

ek fo

r 20m

in

VR ga

me e

xerci

se w

ith IR

EX sy

stem

fo

cusin

g on r

each

ing, li

fting

and

gras

ping;

4 wee

ks: 5

x/we

ek fo

r 60m

in

Prog

ressi

ve ba

lance

train

ing w

ith

visua

l biof

eedb

ack p

lus tr

aditi

onal

traini

ng;

3 wee

ks: 5

x/we

ek

Outc

ome m

easu

res

•St

atic

postu

ral s

way d

ata:

COP

displa

cem

ent i

n A-P

and M

-L

direc

tion

•An

gular

excu

rsion

of lo

wer l

eg,

pelvi

s and

trun

k

•BB

S•

MFE

S•

Timed

50-fo

ot w

alk te

st (T

WT)

•Sim

ple re

actio

n tim

e

•BB

T•

FMA

•M

anua

l Fun

ction

Test

•Se

vera

l fMRI

data

•FM

A•

Gait

evalu

ation

•Ba

rthel

Inde

x•

Mea

sure

men

t of f

uncti

onal

indep

ende

nce (

MFI)

•Sw

ay m

easu

rem

ents

on fo

rcepla

tform

Subj

ects

n=48

; com

mun

ity-d

wellin

g he

althy

olde

r wom

en;

mea

n age

: 70.8

9 ± 5.

67 ye

ars

n=88

; com

mun

ity-d

wellin

g eld

erly;

age r

ange

: 63-

87 ye

ars

n=10

; pat

ients

with

he

mipa

retic

stro

ke;

mea

n age

: 57.1

± 4.

5 yea

rs

n=25

; pat

ients

with

stro

ke;

mea

n age

: 59.5

± 13

.5

Stud

y

Hatzi

taki

et al

,20

09

Hinm

an,

2002

Jang

et

al, 20

05

Kerd

oncu

ff et

al20

04


57

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•BB

S: Sig

nifica

nt di

ffere

nce f

or CB

T-gr

oup a

fter

inter

vent

ion

•AB

C: No

sign

ifica

nt ch

ange

s•

Signifi

cant

decre

ase o

f rea

ction

tim

e in C

BT-g

roup

afte

r inte

rven

tion

•Po

stura

l swa

y: No

sign

ifica

nt ch

ange

s in b

oth

grou

ps

•Ac

cura

cy: Im

prov

emen

ts af

ter in

terv

entio

n and

main

taine

d in

2 of 3

patie

nts

•Sp

eed:

No i

mpr

ovem

ent a

fter in

terv

entio

n for

eithe

r han

d•

Efficie

ncy:

Impr

oved

perfo

rman

ce effi

cienc

y for

all

parti

cipan

ts af

ter in

terv

entio

n •

BBT:

mod

erat

e im

prov

emen

ts•

MAND

: mod

erat

e im

prov

emen

ts

•Tre

atm

ent g

roup

dem

onstr

ated

sign

ifica

ntly

bette

rpe

rform

ance

whe

n com

pare

d with

cont

rols

for

stanc

e sym

met

ry an

d for

func

tiona

l per

form

ance

(A

DL an

d Gro

ss Fu

nctio

n sco

res)

•Sw

ay va

lues s

howe

d a te

nden

cy to

grea

ter

impr

ovem

ent

•St

atist

ically

sign

ifica

nt di

ffere

nces

at th

e end

oftra

ining

for a

ll out

com

e mea

sure

s•

Stat

istica

lly si

gnifi

cant

diffe

renc

es fo

r all o

utco

mes

at 3

mon

ths f

ollow

-up

Cont

rol

No in

volve

men

t in a

ny ty

pe of

tra

ining

None

Balan

ce tr

aining

with

out v

isual

feedb

ack;

4 wee

ks: 3

x/we

ek fo

r 60m

in

None

Inte

rven

tion

Com

pute

rized

Balan

ce Tr

aining

;8 w

eeks

: 2x/

week

for 6

0min

Table

-top V

R-Sy

stem

for m

oving

ob

jects

to cu

ed lo

catio

ns w

ith

augm

ente

d mov

emen

t fee

dbac

k;12

wee

ks: 1

x/we

ek fo

r 60m

in

Balan

ce tr

aining

using

visu

al fee

dbac

k;4 w

eeks

: 3x/

week

for 6

0min

Balan

ce tr

aining

on fo

rce pl

atfo

rm

with

visu

al fee

dbac

k;4 w

eeks

: 5x/

week

for 2

0min

Outc

ome m

easu

res

•BB

S, AB

C•

Audit

ory-

verb

al re

actio

n tes

t•

Postu

ral s

way d

ata

•M

ovem

ent a

ccur

acy

•M

ovem

ent s

peed

•M

ovem

ent e

fficie

ncy

•BB

T•

MAND

•St

ance

sym

met

ry an

d swa

y•

Rive

rmea

d Mot

or A

ssessm

ent

•No

tting

ham

10 Po

int AD

L Sca

le

•BB

S•

Balan

ce In

dex

•Dy

nam

ic Lim

its of

Stab

ility

score

s•

Walk

ing ab

ility

•Ba

rthel

Inde

x

Subj

ects

n=24

; com

mun

ity-d

wellin

g eld

erly;

mea

n age

: IG 70

.3 ye

ars,

CG

71.4

year

s

n=3;

patie

nts w

ith TB

I;m

ean a

ge: 2

0.3 ye

ars

n=26

; stro

ke pa

tient

s;ag

e ran

ge: 4

1-85

year

s

n=45

; stro

ke pa

tient

s;m

ean a

ge: 4

5.51 ±

11.24

ye

ars

Stud

y

Lajoi

e,20

03

Mum

ford

et al

,20

10

Sack

leyet

al,

1997

Sriva

stava

et al

,20

09

Chapter Three

58

Tabl

e 3.4

Inclu

ded s

tudie

s rep

orte

d by s

ubjec

ts, ou

tcom

es m

easu

res,

inter

vent

ion, c

ontro

l and

resu

lts (c

ontin

ued)

Resu

lts

•M

odes

t im

prov

emen

ts in

BBS a

nd Fu

nctio

nal

Reac

h tes

ts•

TUG

time d

ecre

ased

•M

odes

t im

prov

emen

ts in

postu

ral s

tabil

ity te

sts

•Pa

rticip

ants

with

MCI

show

ed s

ignifi

cant

impr

ovem

ents

in PP

T•

Unsp

ecifi

c con

trol p

rogr

am sh

owed

no si

gnifi

cant

effec

ts

•CB

T: im

prov

ed po

stura

l sta

bility

•TC

: no i

mpr

ovem

ents

in po

stura

l sta

bility

, but

redu

ction

of fe

ar of

fallin

g occ

urre

d

•VR

-Gro

up: s

ignifi

cant

impr

ovem

ent i

n all

outco

mes

post-

traini

ng an

d sign

ifica

nt

impr

ovem

ents

in wa

lking

spee

d, CW

T and

WAQ

sco

re 1

mon

th af

ter c

omple

tion o

f pro

gram

•CG

: sign

ifica

nt im

prov

emen

ts in

CWT p

ost-t

raini

ngan

d in f

ollow

-up p

eriod

, sign

ifica

nt im

prov

emen

ts of

WAQ

scor

e at f

ollow

-up

•Sig

nifica

nt im

prov

emen

ts in

the F

MA an

d Mot

ricity

Inde

x sco

res

Abbr

eviat

ions:

BBS =

Berg

Balan

ce Sc

ale; A

BC =

Activ

ities

-spec

ific B

alanc

e Con

fiden

ce Sc

ale; C

B&M

= Fu

nctio

nal B

alanc

e and

Mob

ility;

COP =

Cent

re of

Pres

sure

; COM

= Ce

ntre

of M

ass;

DGI =

Dyn

amic

Gait

Inde

x; TU

G =

Tim

ed U

p an

d Go T

est; T

UG-D

T = Ti

med

Up a

nd G

o Tes

t Dua

l Tas

k; ET

GUG

= Ex

pand

ed Ti

med

Up a

nd G

o Tes

t; M

MSE

= M

ini M

enta

l Sta

te Ex

amina

tion;

ADL =

Activ

ities

of D

aily L

iving

; BBT

= Bo

x and

Bloc

k Tes

t; MA

ND =

Mc C

arro

n Asse

ssmen

t of

Neu

rom

uscu

lar D

ysfu

nctio

n; FM

A = Fu

gl-M

eyer

Asse

ssmen

t of U

pper

Lim

b Mot

or Fu

nctio

n; FE

S-I =

Falls

Effica

cy Sc

ale In

tern

ation

al; M

FES =

Tine

tti’s M

odifi

ed Fa

lls Effi

cacy

Scale

; POM

A = Pe

rform

ance

Orie

nted

Mob

ility

Asse

ssmen

t; FC

WI =

Func

tiona

l Walk

ing Ca

tego

ries I

ndex

; PPT

= Ph

ysica

l Per

form

ance

Test

Cont

rol

None

Sam

e pro

gram

with

phys

ical

reha

bilita

tion p

rogr

am (P

T)

inste

ad of

CCT

Educ

ation

al int

erve

ntion

(ED)

;15

wee

ks: 1

x/we

ek fo

r 60m

in

Tread

mill

traini

ng;

3 wee

ks: 3

x/we

ek fo

r 20m

in

None

Inte

rven

tion

Nint

endo

Wii F

it ba

lance

train

ing

plus s

tand

ard p

hysic

al th

erap

y with

em

phas

is on

func

tiona

l acti

vities

;4 x

45m

in

Com

pute

rized

cogn

itive

train

ing

(CCT)

, occ

upat

ional

ther

apy (

OT)

and b

ehav

ioral

traini

ng (B

T);

3 wee

ks: 4

x/we

ek fo

r 30–

45m

in

Com

pute

rized

Balan

ce Tr

aining

(C

BT) o

r Tai

Chi (

TC);

15 w

eeks

: CBT

1x/w

eek f

or 60

min,

TC

2x/w

eek f

or 60

min

Virtu

al re

ality

-bas

ed tr

eadm

ill tra

ining

;3 w

eeks

: 3x/

week

for 2

0min

Uppe

r lim

b exe

rcise

s with

Ni

nten

do W

ii in a

dditi

on to

usua

l re

habil

itatio

n;2 w

eeks

: 6x/

week

for 3

0min

Outc

ome m

easu

res

•BB

S•

Func

tiona

l Rea

ch•

TUG

•Po

stura

l Sta

bility

Inde

x (ST

I)•

Stab

ility S

core

(ST)

•PP

T•

Basic

and i

nstru

men

tal A

DL

•Po

stura

l sta

bility

mea

sure

men

tsun

der d

efine

d con

dition

s•

Fear

of Fa

lling Q

uesti

onna

ire

•W

alking

spee

d•

Com

mun

ity w

alk te

st (C

WT

•W

alking

Abilit

y Que

stion

naire

(W

AQ)

•AB

C

•FM

A•

Mot

ricity

Inde

x•

Mod

ified

Ash

worth

Scale

(MAS

)•

Visua

l Ana

logue

Scale

for u

pper

limb p

ain

Subj

ects

n=1;

wom

an 5

week

s afte

r str

oke;

age:

86 ye

ars

n=54

; com

mun

ity-d

wellin

g old

er ad

ults w

ith m

ild

cogn

itive

impa

irmen

t (M

CI) or

m

ild de

men

tia (M

D);

age r

ange

: 42–

91 ye

ars

n=72

; inde

pend

ently

living

old

er ad

ults;

mea

n age

: CBT

77.7±

6.5

year

s, TC 7

7.7±

5.6 ye

ars,

Cont

rol G

roup

75.2±

4.9 ye

ars

n=20

; adu

lts w

ith st

roke

;ag

e ran

ge: 3

0–74

year

s

n=16

; reha

bilita

tion

inpat

ients

with

in 3 m

onth

s po

st-str

oke;

mea

n age

: 64.5

± 9.

6 yea

rs

Stud

y

Suga

rman

et al

,20

09

Talas

si et

al,

2007

Wolf

et al

, 19

97

Yang

et al

, 20

08

Yong

Joo

et al

,20

10


59

The blinding of participants and investigators, the assessment of adverse effects, and

the representativeness of the treatment places were also excluded. We considered these

as being of minor significance for this review.

The remaining 20 items were applied by two reviewers (GP, EDdB) to assess the

methodological quality of the studies. The total possible score was 22 points. The

scoring for statistical power (item 27) was simplified to a choice between 0, 1 or 2 points

depending on the level of power to detect a clinically important effect. The scale ranged

from insufficient (β < 70% = 0 points), sufficient (β = 70–80% = 1 point) or excellent (β >

80% = 2 points). To assess the level of agreement between the investigators a Cohen‘s

kappa analysis was performed on all items of the checklist. In accordance with Landis and

Koch‘s benchmarks for assessing the agreement between raters a kappa-score of 0.81–1.0

was considered 'almost perfect', 0.61–0.8 was 'substantial', 0.41–0.6 was 'moderate', 0.21–

0.4 was 'fair', 0.0–0.2 'slight' and scores < 0.0 'poor' [42]. Disagreements were resolved by

consensus.

The PRISMA-statement was followed for reporting items of this systematic review [43].

3.3. Results

3.3.1. Study selection

The search provided a total of 2349 references (Figure 3.1). After adjusting for duplicates,

1697 remained. Of these 1671 were discarded because they provided only physical exercise

(n = 159), did not discuss outcomes or population of interest (n = 89), constituted review

articles or were no interventional studies (n = 217), executed only single tests (n = 246) or

were clearly out of scope of this review (n = 944). The remaining 26 potentially relevant

articles were supplemented by 10 additional references retrieved by citations and author

tracking, resulting in a total of 36 articles being eligible for full-text reading. After full-text

reading eight articles were excluded because they did not report outcomes of interest

(n = 1), applied no intervention (n = 1), applied no training (n = 4), or were theoretical

articles (n = 2). One article appeared to be a written summary of a poster presentation and

represented an included article (n = 1).

Chapter Three

60

Figure 3.1 Study selection flow chart

CINAHL (n = 641)

References identi ed through database searching (n = 2‘349)

Additional records identi ed through citations and author tracking (n = 10)

Excluded duplicates (n = 652)

Articles screened on basis of title and abstract (n = 1‘697)

Excluded (n = 1‘671) • Not outcome or population of interest (n = 89) • Physical exercise ( n = 159) • E ects of physical exercise on cognition ( n = 16) • Reviews, discussions, no intervention etc. ( n = 217) • Tests ( n = 246) • Out of scope (n = 944)

Eligible for full-text reading (n = 26)

Full-text reading and application of inclusion criteria

Included (n = 28)

Excluded (n = 8) • No training (n = 4) • Not outcome of interest (n = 1) • Theortical article (n = 2) • Poster presentation of included article (n = 1)

Dual task strategy (n = 6)

Cognitive rehabilitation intervention

(n = 3 )

Computerized intervention (n = 19)

PsychINFO

(n = 103)

Medline (n = 626)

EMBASE (n = 979)


61

3.3.2. Characteristics of included studies

Of the 28 studies finally selected for the review 27 were published in English [32,44–70]

and one in French [71]. The publication dates range from 1997 [67] to 2010 [48,56,69]. In

the selected studies participants were older adults partially with history of falls [47,70],

balance disorders [47,62], with mild cognitive impairments [65] or osteoporosis [66]. Ten

studies were concerned with patients after stroke [45,49,50,54,57,63,64,68,69,71] and one

study with traumatic brain injury patients [56].

From the 28 included articles three used an isolated cognitive rehabilitation

intervention [44,50,51], seven articles used a dual task intervention [58–62,66,70] and 19

applied a computerized intervention [32,45–49,52–57,63–65,67–69,71]. From the seven

articles concerning dual-tasking two articles arise from the same intervention [60,61]

leading us to regard it as one single study.

In 22 studies, a cognitive rehabilitation intervention, dual task training or a

computerized intervention were used as the only intervention for the participants [32,45–

47,49–52,54–63,66–70]. In six studies the interventions were applied as additional items

to a traditional physical or balance training [44,48,53,64,65,71]. The reported outcomes

involved different assessments of balance, gait or functional mobility.

Balance was assessed with the help of postural sway measurements

[32,44,51,52,57,62,67,71], with the Berg Balance Scale [44,47,49,51,53,55,60–64], with

the Activities-specific Balance Confidence Scale [44,47,49,51,55,60–62,68], with the

Functional Balance and Mobility test [32], with the Balance Index [63] and with one-leg-

stance tests [59,66]. Gait measurements included measurements of kinematic parameters

[44,48–50,60,61,68,70], the Timed Up & Go Test [44,47–49,62,64,66], the Dynamic Gait

Index [47,49,62], or step recording with pedometers [58]. Functional Mobility assessments

were determined by manual ability measurements [45,54], functional reach tests [64], the

Physical Performance Test [65], the Rivermead Motor Assessment [57], The Nottingham 10

Point ADL Scale [57], the Box and Block Test [45,54,56] and the Fugl-Meyer Assessment of

Upper Limb Motor Function [50,54,69,71].

Chapter Three

62

3.3.3. Methods used and their effects

3.3.3.1. Cognitive rehabilitation interventions

From the three articles evaluating the effects of a cognitive rehabilitation intervention on

motor outcomes, two examined the effects of mental imagery on physical functioning of

older adults aged between 65 and 90 years [44,51]. In the third study, the participants were

community-dwelling adults between 44 and 79 years of age suffering from hemiparetic

stroke [50]. The three studies investigated the effect of mental imagery training on postural

balance [44,51] and on gait [44,50]. Mental imagery training consisted of either visual

imagery training, i.e. participants are expected to view themselves from the perspective

of an external observer, or of kinesthetic imagery exercise, i.e. participants imagine

experiencing bodily sensations that might be expected in the exercise. The trainings

lasted six weeks with a training frequency ranging from daily [51], twice weekly [44] to three

times weekly [50]. Two studies used a pure cognitive rehabilitation method [50,51] whereas

one study combined mental practice with additional physical exercise [44].

The studies show reduction of postural sway [51], and improvements in gait speed [44]

and gait symmetry [50]. No improvements were shown for balance confidence [44].

Hamel and Lajoies‘ [51] results show a significant reduction of anterior-posterior

postural oscillations suggesting that mental imagery training over a six-week period helps

to improve postural control of the elderly. The study of Batson et al. [44] combined mental

imagery with physical exercise. The control group underwent a health education program

in addition to the physical training. Gait speed, expressed by improvement in Timed Up-

and-Go test performance, increased for all study participants. These results imply that

the improvement in gait speed were attaint through the physical practice regardless

of whether combined with mental imagery or not. This conjecture is supported by the

fact that the two groups under observation converge to each other for the Timed Up-

and-Go test measures following the intervention. In the pretest phase, there was a large,

meaningful difference for the Timed Up-and-Go test between the mental imagery and

physical practice subjects (Cohen‘s d = 1.2) that decreases to Cohen‘s d = 0.55 at the end

of intervention. The results showed no improvement in balance confidence, as expressed


63

by non-significant results neither on the Berg Balance Scale nor on the Activities-specific

Balance Confidence Scale. The study of Dunsky et al. [50] showed improvements of

spatiotemporal gait parameters and gait symmetry in people with chronic poststroke

hemiparesis after mental imagery. There was no control group in this study to support

these results.

3.3.3.2. Dual task interventions

The methods varied from walking or balancing with a concurrent mental task like

memorizing words, reciting poems, or computing mental arithmetic tasks [60–62,66,70]

to a square-stepping exercise where participants executed forward, backward, lateral

and oblique step patterns on a thin felt mat [58,59]. The training lasted between 4 weeks

[60–62], 6 weeks [70] or 12 weeks [58,59,66]. No dual task study was found on stroke

patients or people with traumatic brain injury. The study of Shigematsu et al. [58] showed

improvements in functional fitness of lower extremities. The results on gait patterns

and postural sway are controversial. Silsupadol et al. [60–62] showed improvement of

gait speed under dual task conditions and a reduction of body sway, whereas You et al.

[70] and Vaillant et al. [66] found no improvements in gait and stability after a dual task

intervention. No other physical outcomes were reported.

The studies conducted by Silsupadol et al. [60–62] compared three different balance

training approaches: single task balance training, dual task balance training with fixed-

priorities and dual task balance training with variable-priority. Single task training

consisted of exercises for body stability with or without object manipulation and/or body

transport. In the dual task condition, concurrent auditory and visual discrimination tasks

and computing tasks were added to the balance training. In the fixed-priority condition

the subject was instructed to direct the attention with equal priority to both the postural

and additional tasks. In the variable-priority condition half the training was done with the

instruction to mainly prioritize the postural task and the other half with the instruction

to mainly prioritize the additional task. All participants improved self-selected gait speed

under single task testing conditions. Under dual task testing conditions, however, only

Chapter Three

64

participants who received dual task training showed significant improvements in self-

selected gait speed (with moderate effect sizes of 0.57 between single task and fixed-

priority and 0.46 between single task and variable-priority). All groups significantly

improved on the Berg Balance Scale under single task conditions. Participants in the

variable-priority training group additionally showed an average of 56% reduction in body

sway compared to only 30% of the fixed-priority and single task group. Overall, the study

showed that variable-priority instruction was more effective in improving both balance

and physical performance under dual task conditions than either the single task or the

fixed-priority training approaches. In contrast to the fixed-priority training group, the

variable-priority group showed long-term maintenance effects on dual task gait speed for

three months after the end of training.

In contrast to the results of Silsupadol et al., You and colleagues [70] found no

improvements in gait and stability after their dual task intervention that lasted six weeks.

Results of the gait tests showed a significant increase in gait velocity in the control group,

which underwent single task training, but not in the experimental group. No statistically

significant differences in the deviation of medio-lateral and anterior-posterior center

of pressure were found between the groups. Vaillant et al. [66] did not find additional

improvements through the addition of a cognitive task to the physical task either. The

exercise sessions were effective in improving performance on two balance tests,

improvements, however, were not attributable to the dual task training.

Shigematsu et al. [58,59] developed an alternative approach to exercise for dual

task abilities in community-dwelling older adults. A square-stepping exercise was

performed on a thin mat with the instruction to step from one end of the mat to

the other according to a step pattern provided, which could be made progressively

more complex. Results showed that square-stepping exercise was equally effective

as strength training to improve lower-extremity functional fitness. Compared to a

weekly walking session, however, participants of the square-stepping exercise group

showed a greater improvement in functional fitness of the lower-extremity.


65

3.3.3.3. Computerized interventions

Nineteen studies investigated the effects of a computerized intervention to improve

physical abilities. The studies were distributed over the populations of interest as follows:

nine interventions treating older adults [32,46–48,52,53,55,65,67], nine interventions

treating patients with stroke [45,49,54,57,63,64,68,69,71] and one study treating young

adults with traumatic brain injury [56]. Fifteen studies investigated the effects on lower

extremities [32,46–49,52,53,55,57,63–65,67,68,71], whereas four studies analyzed the

effects on upper extremities [45,54,56,69]. The interventions included various methods

and ideas for the implementation of computers into a training session. Talassi et al. [65]

used a computerized cognitive program [72,73], to stimulate cognitive functions, e.g.

visual search, episodic memory or semantic verbal fluency, by a specific group of exercise

for older adults with mild cognitive impairments or mild dementia. Buccello-Stout et

al. [46] used a sensorimotor adaptation training to improve functional mobility in older

adults. Participants walked on a treadmill while viewing a rotating virtual scene providing

a perceptual-motor mismatch [46].

Seven studies used the method of computerized dynamic balance training with

visual feedback technique [52,53,55,57,63,67,71]. The tasks required to move a cursor

through weight-shifting on a screen representing the center of pressure (COP) position

to specified targets [32,53,55,63,67] or on a predefined sine wave trajectory [52]. In one

study, the feedback signal displayed the weight distribution and weight-shifting with

moving columns, showing stance symmetry [57]. In another study researchers designed

the task of visual feedback training in a more playful way, projecting the cursor for center

of pressure as a caterpillar moving on the screen [71].

A total of ten studies described an approach, which included interactive virtual reality

games or applications [32,45,47–49,54,56,64,68,69]. Seven studies out of this ten were

conducted on stroke patients [32,45,49,54,64,68,69], two studies on older adults [47,48]

and one on patients with traumatic brain injury [56]. The virtual reality applications

were varied. There were elaborated and expensive systems, enabling the participants

to see themselves in the virtual environment and to play games like juggling a virtual

Chapter Three

66

ball [32] or saving a ball as a soccer keeper [54]. Virtual devices consisting of a semi-

immersive workbench with which participants were able to reach and interact with three-

dimensional objects [45], a table-top virtual reality based system requiring the patients to

move an object to cued locations while receiving augmented movement feedback [56]

and virtual reality based treadmill training [68]. Furthermore, commercially available low-

cost interactive video game console systems [47,49,64,69] or dance simulation games [48]

were applied.

The computerized cognitive training program proposed by Talassi et al. [65] produced

an improvement in functional status, measured by the Physical Performance Test [74],

in patients with mild cognitive impairments, while a physical rehabilitation program did

not show any significant effects. The sensorimotor adaptation training for older adults

developed by Buccello-Stout et al. [46] resulted in better performance on an obstacle

course after the intervention compared to the control group, who walked on the treadmill

without rotation of the virtual scenario.

Some of the interventions providing balance training with visual feedback improved

simple auditory reaction time [32,55] postural balance and stability [32,55,57,63,67,71], gait

speed [63], functional status, and performance [55,57,63,71]. The intervention conducted

by Hatzitaki et al. [52] revealed that weight-shifting training in anterior-posterior direction

only induces improvements in standing balance of older adults. In contrast, the studies

of Lajoie et al. [55] and Bisson et al. [32] showed no improvements in postural sway after

computerized balance training in older adults. Hinman and colleagues [53] also found no

improvements neither in balance, gait speed nor in simple reaction time compared to the

control group. The results of Kerdoncuff et al. [71] even showed a reduction of gait speed

in stroke patients treated with visual biofeedback compared to an increase in gait speed

for the control group treated with a traditional physical rehabilitation program.

The methods using immersive computer technologies resulted in improved motor

functions of upper extremities and a cortical activation by the affected movements

from contralesional to ipsilesional activation in the laterality index after virtual reality

intervention in patients with chronic stroke [54]. Older adults benefited from training


67

in terms of improved functional abilities, postural control and simple auditory reaction

times [32]. A virtual rehabilitation program with the help of a semi-immersive virtual

reality workbench, in a non-hospital environment, resulted in qualitatively improved

manual trajectories and increased movement velocity of the trained upper extremities for

patients with stroke, without any transfer to real-life activities [45].

A virtual reality based treadmill intervention conducted by Yang et al. [68] requested

patients with stroke to walk on a treadmill while observing a virtual scenario of the

typical regional community. The scenarios consisted of lane walking, street crossing,

striding across obstacles, and park stroll with increasing levels of complexity. Participants

improved their walking speed and walking ability at post-training as well as after one

month after the training.

Effects on motor functions were also observed in studies using so-called off the shelf

computer game systems. Four studies proposed a training program using the Nintendo

Wii console [47,49,64,69]. Three of them were case studies and exemplified that a training

with a commercially available computer game system can be applied for older adults [47]

and for the treatment of balance problems after stroke [49,64]. The participants performed

physical training using the Wii Fit system. Using the approach of the weight- shifting

method with visual feedback, the Wii Fit games were controlled by shifting body weight

on the platform combined with a challenging game [64]. The activities on the Nintendo

Wii console were selected to practice balance, coordination, strengthening, endurance

or bilateral upper extremity coordination [47,49]. Subjects very much enjoyed the

interventions resulting in better balance and mobility performance [47,64], improvements

in gait speed, gait endurance and balance [49]. A recently published study using the

Nintendo Wii console [69] resulted in improvements in upper extremity functions in post

stroke patients.

A study conducted by de Bruin et al. [48] studied the transfer effects on gait

characteristics of elderly who executed a traditional progressive physical balance and

resistance training with integrated computer game dancing. The task of the dancing

game consisted of stepping on arrows on a dance pad. Results indicated a positive effect

Chapter Three

68

of the computer game dancing training on relative dual task costs of walking, e.g., stride

time and step length. The more traditional physical training showed no transfer effects on

dual task costs related gait characteristics.

3.3.4. Quality evaluation

The agreement on study quality between the two reviewers was 'almost perfect'. The

estimated Kappa value was 0.96 with a confidence interval ranging between 0.95 and 0.98.

The percentage of agreement between the two reviewers was 98.18%. The quality scores

ranged from 7 to 22 points out of a maximum of 22. The mean quality score was 13.46

points (range: 7–22 points), the median value was 6.5 points and the mode was 12 points.

The mean score for reporting was 6.57 points (maximum: 9 points; range: 4–9 points), for

external validity 0.68 (maximum: 2 points; range: 0–2 points), for internal validity (bias)

3.71 points (maximum: 5 points; range: 2–5 points), for internal validity (confounding)

2.25 (maximum: 4 points; range: 0–4 points).

Table 3.5 summarizes the results of the quality assessment for the three intervention

types: cognitive rehabilitation interventions, dual task interventions, and computerized

interventions.

3.4. Discussion

An increased incidence of falls among older adults is one of the most serious problems

of mobility impairment. It has been suggested that effective programs to prevent falls in

older adults should focus on training both physical and cognitive aspects. The aim of this

systematic review was to examine the literature on the effects of cognitive and cognitive-

motor interventions to improve physical functioning of older adults with additional

insights from studies conducted with brain injured adults or patients with stroke.

Our search resulted in relatively few studies that evaluated a cognitive or a cognitive-

motor intervention. Twenty-eight articles were found including studies with older adults

or patients with neurological impairments. Our results show that the method of combining

physical exercise with cognitive elements to improve physical functioning is not yet


69

Table 3.5 Assessment of methodological quality

Reporting External validity Internal validity Bias

Internal validityConfounding

Study Hypo

thes

is/aim

/obje

ctive

clea

rly de

scribe

d

Main

outco

mes

clea

rly de

scribe

d in t

he in

trodu

ction

or m

etho

ds se

ction

Parti

cipan

ts’ ch

arac

teris

tics c

learly

descr

ibed

Inte

rven

tion c

learly

descr

ibed

Dist

ribut

ion of

princ

ipal c

onfo

unde

rs cle

arly

descr

ibed

Main

findin

gs of

the s

tudy

clea

rly de

scribe

d

Estim

ation

of ra

ndom

varia

bility

for m

ain ou

tcom

es pr

ovide

d

Actu

al pr

obab

ility v

alues

repo

rted (

e.g. 0

.035 r

athe

r tha

n <0.0

5)

Tota

l (m

ax: 9

)

Subje

cts as

ked t

o par

ticipa

te re

pres

enta

tive f

or th

e ent

ire po

pulat

ion fr

om w

hich t

hey w

ere d

erive

d

Subje

cts pr

epar

ed to

parti

cipat

e rep

rese

ntat

ive of

the e

ntire

popu

lation

from

whic

h the

y wer

e rec

ruite

d

Tota

l (m

ax 2)

Atte

mpt

to bl

ind th

ose m

easu

ring t

he m

ain ou

tcom

es

No r

etro

spec

tive u

nplan

ned s

ubgr

oup a

nalys

es

Stat

istica

l tes

ts us

ed to

asse

ss th

e main

outco

mes

appr

opria

te

Com

plian

ce w

ith in

terv

entio

n/s r

eliab

le

Main

outco

me m

easu

res a

ccur

ate (

valid

and r

eliab

le)

Tota

l (m

ax: 5

)

Patie

nts i

n diff

eren

t int

erve

ntion

grou

ps

Patie

nts r

ecru

ited o

ver t

he sa

me p

eriod

of ti

me

Stud

y sub

jects

rand

omize

d to i

nter

vent

ion gr

oups

Adeq

uate

adjus

tmen

t for

conf

ound

ing

Tota

l (m

ax: 4

)

Powe

r (m

ax: 2

)

Tota

l Sco

re (m

ax: 2

2)

COG

Batson 1 1 1 1 0 1 0 0 5 0 0 0 0 1 1 1 1 4 1 1 1 0 3 0 12

Dunsky 1 1 1 1 0 1 1 0 6 1 1 2 0 1 1 1 1 4 0 0 0 0 0 2 14

Hamel & Lajoie

1 1 1 1 0 0 0 0 4 0 0 0 0 1 1 0 1 3 1 1 1 0 3 0* 10

DT

Shigematsua 1 1 1 1 2 1 1 1 9 1 1 2 1 1 1 1 1 5 1 1 1 1 4 2 22

Shigematsub 1 1 1 1 2 1 1 1 9 0 0 0 0 1 1 1 1 4 1 1 1 1 4 2 19

Silsupadol 2006

1 1 1 1 0 1 0 0 5 0 0 0 0 1 0 1 1 3 0 0 0 0 0 0 8

Silsupadol 2009

1 1 1 1 2 1 1 1 9 0 0 0 1 1 1 1 1 5 1 1 1 1 4 0 18

Vaillant 1 1 1 1 0 1 1 1 7 1 1 2 0 1 1 1 0 3 1 1 1 0 3 0 15

You 1 1 1 1 2 1 1 1 9 0 0 0 0 1 1 0 1 3 1 1 1 0 3 0 15

COM

Bisson 1 1 1 1 0 1 0 0 5 1 1 2 0 1 1 1 1 4 1 1 0 0 2 0* 13

Broeren 1 1 1 1 1 1 1 0 7 0 0 0 0 1 0 0 1 2 0 0 0 0 0 0 9

Buccello-Stout

1 1 1 1 1 1 0 0 6 1 0 1 0 1 1 1 1 4 1 1 1 0 3 0* 14

Clark 1 1 0 1 0 1 0 0 4 0 0 0 0 1 0 1 1 3 0 0 0 0 0 0 7

de Bruin 1 1 1 1 1 1 1 1 8 1 0 1 0 1 1 1 1 4 1 1 0 1 3 0 16

Deutsch 1 1 1 1 0 1 0 0 5 0 0 0 1 1 0 1 1 4 0 1 1 0 2 0 11

Hatzitaki 1 1 0 1 0 1 1 0 5 1 0 1 0 1 1 0 1 3 1 1 1 0 3 0 12

Hinman 1 1 0 1 0 1 1 1 6 1 0 1 0 1 1 0 1 3 1 1 1 0 3 0 13

Jang 1 1 1 1 2 1 1 0 8 0 0 0 1 1 1 1 1 5 1 1 1 1 4 0 17

Kerdoncuff 1 1 1 1 1 1 1 1 8 1 0 1 0 1 1 1 1 4 1 1 1 1 4 0 17

Lajoie 1 1 1 1 0 1 1 0 6 0 0 0 0 1 1 0 1 3 1 1 0 0 2 0* 11

Mumford 1 1 1 1 0 1 0 0 5 0 0 0 0 1 1 1 1 4 0 0 0 0 0 0 9

Sackley 1 1 1 1 2 1 1 0 8 1 0 1 1 1 1 1 1 5 1 1 1 1 4 1 19

Srivastava 1 1 1 0 0 1 1 0 5 0 0 0 0 1 1 1 1 4 0 0 0 0 0 0* 9

Sugarman 1 1 0 1 0 1 0 0 4 0 0 0 0 1 0 1 1 3 0 0 0 0 0 0 7

Talassi 1 1 0 1 1 1 1 1 7 1 0 1 0 1 1 1 1 4 1 1 0 0 2 0 14

Wolf 1 1 1 1 2 1 1 1 9 0 0 0 0 1 1 1 0 3 1 1 1 1 4 0 16

Yang 1 1 1 1 1 1 1 1 8 1 1 2 1 1 1 1 1 5 1 1 1 0 3 0 18

Yong Joo 1 1 1 1 0 1 1 1 7 1 1 2 0 1 1 0 1 3 0 0 0 0 0 0 12

Abbreviations: COG = Cognitive Rehabilitation Intervention; DT = Dual task Intervention; COM = Computerized Intervention; * unable to determine

Chapter Three

70

systematically part of the current interventions for older adults or patients with neurological

impairments. The methodological heterogeneity and the numerous feasibility studies are

indicators for a topic still being in its fledgling stage.

The results of the few studies identified in this review, however, justify larger studies

with older adults. There is evidence that cognitive or cognitive-motor interventions

positively affect physical functioning, such as postural control, walking abilities and

general functions of upper and lower extremities. The majority of the included studies

resulted in improvements of the assessed functional outcome measures. The next sections

will discuss the three different intervention types applied in more detail.

3.4.1. Cognitive rehabilitation interventions

The prevalent technique used was mental imagery, which involved the participants

imagining themselves in a specific environment or performing a specific activity, without

actually performing it [75]. Brain-imaging studies showed that comparable brain areas

are activated during actual performance and during mental rehearsal of the same tasks

[76,77]. Hamel and Lajoie [51] suggest that after mental imagery the motor control task

becomes more automatic, leading to a decrease in attentional demands directed toward

the control of the motor task.

Our search resulted in three relevant studies that applied mental imagery. In one study

[44] improvements in physical functioning were shown in both the intervention and the

control group and in a second study [50], a missing control group made it impossible to

assess whether improvements in physical functioning were attained through mental

practice or not. Thus, as for now it is not possible to determine whether an isolated

cognitive rehabilitation intervention based on mental imagery is able to improve

physical functioning in older adults. There is evidence about the effectiveness of

mental imagery in improving physical functioning of other populations than older

adults [25,75]. It seems fair to state that larger randomized control studies should

be performed in order to provide more insights in the impact of mental imagery in

older adults.


71

3.4.2. Dual task interventions

Research has shown that dual task interventions may help participants to automate a

task, to focus on other tasks and consequently, to free the individual‘s processing capacity.

After dual task exercise more attention is available to process external information and

therefore to react faster on sudden disturbances [32]. The included studies showed that

it was generally feasible to apply dual task interventions, namely combining a traditional

physical intervention with a variety of cognitive tasks, in community-dwelling older

adults with balance impairments. During the selection stage of this review, numerous

studies were identified studying the dual task abilities of older adults, though only six

studies were found which integrated the method of dual-tasking in a program designed

to improve physical functioning. Two studies included relatively simple cognitive tasks

like computing or reciting poems. Both studies showed no improvements in physical

functioning that were clearly attributable to the dual task intervention.

Using dual task exercises with variable-priority or using a complex stepping task may

both be closer to real-life conditions as compared to computing while walking. The studies

of Silsupadol et al. [60-62] and Shigematsu et al. [58,59] applied a more challenging way

of attention-demanding tasks, and, presumably thus, offered advantages in terms of

rate of learning compared to more simple cognitive tasks. Results show improvements

in functional fitness of lower extremities, balance and gait speed. The latter has been

reported as a global indicator of functional performance in older adults and is a good

predictor of falls [78].

Shigematsu and colleagues in addition provided a challenging leg exercise, which was

suggested to enhance neural functions by reducing response latency and by effectively

recruiting postural muscles resulting in an improving of the interpretation of sensory

information. Caution seems to be indicated in relation to the transfer effects of this form

of training. The pre- and post-tests that were used to assess the effects of training were

similar to the cognitive and motor tasks assigned in the interventions. Thus, it cannot be

excluded that learning effects were observed instead of real improvements in underlying

functional motor skills. From this viewpoint, it is not surprising that participants in dual

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72

task groups performed better in the post-tests.

The dual task interventions showed satisfying study quality with a mean of 16.2

points out of a maximum of 22 points. However, the results about the effect of dual task

interventions on physical functioning are controversial. In addition, analogue to the

cognitive rehabilitation interventions, the limited number of studies performing dual task

training hampers a generalization of results.

3.4.3. Computerized interventions

Computerized interventions varied from force platforms with visual biofeedback with

relatively simple graphics [52,53,55,57,67,71], to video capture systems that enabled the

participant to see her/himself on a screen with attractive and realistic graphics allowing

to immerge into the virtual environment [32,46,54,68]. A third set of studies used

commercially available video game consoles that combined the simplicity of a weight-

shifting training on a platform with the elaborated graphics and motivating games of a

video capture system [47-49,64,69]. The study quality of the computerized interventions

articles was lower (mean value of 12.8 points out of a maximum of 22 points) as

compared with the value of the dual task studies (16.2 points). In contrast to the dual task

interventions, however, the results of the computerized interventions showed a consistent

positive effect on various physical abilities in older adults, patients with traumatic brain

injury, and stroke patients. Computerized interventions can also be effectively used in

clinical settings. Remarkable is that every study reported that participants were more

motivated and compliant with the computerized setting in comparison to conventional

physical training programs. Computerized interventions may have engaged people who

otherwise would lack interest to undergo a traditional exercise program.

The effects of the video games on cognitive aspects of the participants have,

remarkably, not been a specific focus of the various studies. It seems, however, that

computer games have the potential to also train cognitive functions [34], including

attention and executive functions [22]. Combined with physical exercise a video game or

a virtual environment requires sensory-motor function inputs as well as cognitive inputs.


73

The participant is required to orientate her/himself, attend, comprehend, recall, plan

and execute appropriate responses to the visual cues provided on the screen [69]. The

visual aspect is crucial since with aging, vision remains important in maintaining postural

control [79]. Virtual environments have also the potential to specifically include motor

learning enhancing features that activate motor areas in the brain [80]. In addition You

and colleagues suggest that virtual reality training could induce reorganization of the

sensorimotor cortex in chronic patients [81].

As we know from the principles of motor learning, repetition is important for both

motor learning and the cortical changes that initiate it. The repeated practice must

be linked to incremental success at some task or goal. A computerized intervention

constitutes a powerful tool to provide participant repetitive practice, feedback about

performance and motivation to endure practice [82]. In addition, it can be adapted

based on an individual participant‘s baseline motor performance and be progressively

augmented in task difficulty. Weiss and colleagues [83] suggested that virtual reality

platforms provide a number of unique advantages over conventional therapy in trying to

achieve rehabilitation goals.

First, virtual reality systems provide ecologically valid scenarios that elicit naturalistic

movement and behaviors in a safe environment that can be shaped and graded in

accordance to the needs and level of ability of the patient engaging in therapy. Secondly,

the realism of the virtual environments gives patients the opportunity to explore

independently, increasing their sense of autonomy and independence in directing their

own therapeutic experience. Thirdly, the controllability of virtual environments allows for

consistency in the way therapeutic protocols are delivered and performance recorded,

enabling an accurate comparison of a patient‘s performance over time. Finally, virtual

reality systems allow the introduction of „gaming“ factors into any scenario to enhance

motivation and increase user participation [84]. The use of gaming elements can also

be used to take patients‘ attention away from any pain resulting from their injury or

movement. This occurs the more a patient feels involved in an activity and again, allows

a higher level of participation in the activity, as the patient is focused on achieving goals

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74

within the game [85]. In combination with the benefits of indoor exercises such as safety,

independence from weather conditions, this distraction may result in a shift from negative

to positive thoughts about exercise [17].

3.4.4. General methodological considerations

A central element of successful cognitive rehabilitation for older adults should be the

design of interventions that either re-activate disused or damaged brain regions, or that

compensates for decline in parts of the brain through the activation of compensatory

neural reserves [86]. Cognitive activity or stimulation could be a protective factor against

the functional losses in old age. Because spatial and temporal characteristics of gait are

also associated with distinct brain networks in older adults it can be hypothesized that

addressing focal neuronal losses in these networks may represent an important strategy

to prevent mobility disability [87]. Interventions should, as previous research suggests,

focus thereby on executive functioning processes [9], and in particular on the executive

function component divided attention [11], and should include enriched environments

that provide physical activities with decision-making opportunities because these

are believed to be able to facilitate the development of both motor performance and

brain functions [88]. This review encourages the further development of virtual reality

interventions, preferably with a randomized control design.

Future research that aims to examine the relation between virtual reality environments

and improvements in both cognitive and walking skills, and the translation to better

performance on selected physical tasks, should design the training content such that the

relation between the cognitive and physical skills are more explicitly taken into account,

e.g. specific elements of divided attention are integrated in the scenario. Many of the

studies of this review were small and may have lacked statistical power to demonstrate

differences, if such differences were present. In addition, the interventions were of relatively

short duration and heterogeneous in their design, and most subjects investigated were

stroke survivors. Most studies did not specifically focus on physical functioning outcomes

from which it is known that these relate to brain functioning. For example, spatial and


75

temporal dual task cost characteristics of gait are especially associated with divided

attention in older adults [11], and are dependent of the nature of the task investigated

(preferred versus fast walking).

3.4.5. Future directions

Future research that aims to examine the relation between improvements in cognitive

skills and the translation to better performance on selected physical tasks should take

the relation between the cognitive and physical skills into account. The majority of the

authors, and above all this holds true for the studies using computerized interventions,

does not specifically mention or is even not aware of the potential cognitive aspects of

their interventions.

3.4.6. Limitations

We developed and utilized a structured study protocol to guide our search strategy, study

selection, extraction of data and statistical analysis. However, limitations of this review

should be noted. First, a publication bias may have been present, as well as a language

bias, given that we considered only interventions described in published studies and

restricted our search to English, French, and German language publications. Second, as

there were only few randomized trials, we also included observational studies, the results

of which may be affected by confounding bias due to the absence of random assignment.

An additional limitation is that we did not investigate the effect of the interventions in

separate populations. One study included in the analysis for example assessed subjects

with MCI and dementia [65]. It can very well be argued that the results of cognitive

interventions may be expected to be different between cognitively intact, MCI, and

demented subjects. This point should be considered in future reviews on this topic.

3.5. Conclusions

The current evidence on the effectiveness of cognitive or cognitive-motor interventions

to improve physical functioning in older adults or patients with traumatic brain injury is

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limited. Yet overall, as the most studies included in this review showed, these interventions

can enhance physical functioning. The heterogeneity of the studies published so far does

not allow defining the training methodology with the greatest effectiveness. This review

nevertheless provides important foundational information in order to encourage further

development of novel cognitive or cognitive-motor interventions, preferably with a

randomized control design. Future research that aims to examine the relation between

improvements in cognitive skills and the translation to better performance on selected

physical tasks should take the relation between the cognitive and physical skills into

account. The majority of the authors, and above all this holds true for the studies using the

computerized design, does not specifically mention or is even not aware of the potential

cognitive aspects of their interventions.

Acknowledgements

The authors would like to thank Dr. Martina Gosteli of the Medicinal Library of the

University of Zurich for her help in elaborating the search strategy.

Authors‘ contributions

Conception and design: GP, EDdB; screening: GP, EDdB, data abstraction: GP, EDdB; data

interpretation: GP, EDdB; manuscript drafting: GP, EDdB, PW; KM, GP, EDdB and PW critically

revised the manuscript for its content and approved its final version.

Competing interests

The authors declare that they have no competing interests.


77

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Four

The effect of a cognitive-motor intervention on voluntary step

execution under single and dual task conditions in older adults:

a randomized controlled pilot studyPichierri G1, Coppe A1, Lorenzetti S2, Murer K1 and de Bruin ED1


2Institute for Biomechanics, Department of Health Sciences and Technology, ETH Zurich,

Switzerland

published in Clinical Interventions in Aging 2012:7 175–184

Ch

ap

ter

Chapter Four

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Abstract

Background: This randomized controlled pilot study aimed to explore whether a cognitive-

motor exercise program that combines traditional physical exercise with dance video

gaming can improve the voluntary stepping responses of older adults under attention-

demanding dual task conditions.

Methods: Elderly subjects received twice weekly cognitive-motor exercise that included

progressive strength and balance training supplemented by dance video gaming for 12

weeks (intervention group). The control group received no specific intervention. Voluntary

step execution under single and dual task conditions was recorded at baseline and post

intervention (Week 12).

Results: After intervention between-group comparison revealed significant differences for

initiation time of forward steps under dual task conditions (U = 9, p = 0.034, r = 0.55) and

backward steps under dual task conditions (U = 10, p = 0.045, r = 0.52) in favor of the

intervention group, showing altered stepping levels in the intervention group compared

to the control group.

Conclusion: A cognitive-motor intervention based on strength and balance exercises with

additional dance video gaming is able to improve voluntary step execution under both

single and dual task conditions in older adults.

Keywords: fall prevention, exercise, dance, video game

Voluntary step execution

89

4.1. Introduction

Appropriate timing and execution of stepping responses is needed for the effective

avoidance of falls [1]. With age, the speed of these responses inevitably declines due to

changes in the sensory and motor systems [2,3]. Consequently, individuals who require

more time to initiate and execute a step to avoid a threat or to recover postural balance,

either during walking or performing postural transitions [4], may be at greater risk of

falling [5].

Considerable evidence has been accumulated showing that an additional secondary

cognitive dual task causes postural instability in older adults, and thus, a delay in step

execution [6,7]. Postural balance control requires, among other things, the integration of

visual, somatosensory, and vestibular inputs, as well as the adaptation of these inputs to

changes in tasks and environmental context [6]. Maintenance and regulation of postural

balance require a high information processing capacity, and a more difficult motor task

may demand an amount that exceeds the capacity of the available resources [8].

Reduced step execution capabilities can be mitigated by exercise, and improvements

in voluntary step execution after exercise interventions have been reported in older adults

[5,9–11] and patients after stroke [12]. However, these improvements have been tested

without any additional cognitive distraction, which questions the ecological validity of

the findings; that is, it can be questioned whether the action within the test condition

is equivalent to the motor performance requirements within the physical environment.

Physical exercise alone does not contribute to an improvement of voluntary stepping

performance under attention-demanding conditions [10].

A recently published systematic review supports the recommendation that a cognitive

element should be part of an exercise program for older adults since falls often occur

under attention-demanding circumstances [13]. A way to incorporate a cognitive element

into an exercise program is the use of virtual reality techniques in the form of dance video

gaming [14]. Games based on this technique require players to stand on a dance pad and

make rapid step responses from either leg to a target location in response to a presented

visual stimulus [15]. It involves controlled body weight transfer, which is similar to the step

Chapter Four

90

responses required to cope with external threats in everyday life; thus, we hypothesized

that the game has the potential to improve voluntary step execution under attention-

demanding circumstances. Previous dance pad studies have shown the feasibility of this

approach in the elderly and have reported positive contributions to self-reported balance

confidence and mental health in older adults [15,16]. Furthermore, there are strong

indications that the addition of dance video gaming has a positive effect on dual task

walking in older adults [17].

New treatments usually have to go through a series of pilot studies to test whether

they are safe and effective [18]. The aim of this pilot study was to perform a phase II trial

according the model for complex interventions, advocated by the British Medical Research

Council [19] to test a traditional strength and balance training program that also includes

dance video gaming in a group of elderly people in order to receive an estimation of the

treatment effect and its variations. The study aimed to explore whether this cognitive-

motor exercise program is able to improve the voluntary stepping responses of older

adults under attention-demanding dual task conditions.

4.2. Material and methods

4.2.1. Participants

The study was designed as a prospective, randomized, controlled pilot trial and was carried

out from October 2010 to January 2011 with participants recruited from two care homes

in Zurich, Switzerland. The study protocol was approved by the local ethics committee

(KEK-ZH-NR 2010-0337/0). The exercise intervention was conducted in suitable locations

at the care homes. The measurements of voluntary step execution were performed in the

laboratory of the Institute for Biomechanics of the ETH Zurich, Switzerland.

All residents of the care homes were invited to attend an information session in which

the intervention was explained. Thirty-four persons attended the information session, and

30 were interested in participating in the study. Participants were included if they were older

than 65 years, had a score of at least 22 points on the Mini-Mental State Examination [20],

were able to stand upright for at least 5 minutes, and were free of rapidly progressive or


91

terminal illness, acute illness, or unstable chronic illness. If unsure, subjects were asked

to consult their primary care physician for medical clearance. Interested individuals were

contacted by the investigator seven days later for an individual appointment to clarify any

remaining questions and to sign an informed consent statement.

Three persons refused to participate due to insufficient motivation. Two interested

persons who used wheelchairs were excluded because they did not fulfill the inclusion

criteria. A total of 25 eligible residents signed informed consent statements and were

randomly assigned to either the usual care control group (CG) or the intervention

group (IG). Eleven participants were allocated to the CG and 14 participants to the IG

using a random numbers table. Blinding of investigators was not possible because the

investigators supervised and conducted the training sessions.

4.2.2. Intervention

The IG underwent a cognitive-motor intervention consisting of twice weekly progressive

resistance training, progressive postural balance training, and progressive dance video

gaming for twelve weeks. Intensity and duration of the program were chosen based on

guidelines published by the American College of Sports Medicine [21,22] and on a review

by Paterson et al describing exercise recommendations for older adults [23]. Training

sessions were conducted in groups of three or four participants to form group cohesion

and to encourage exercise class participation [24]. A training session lasted 60 minutes and

consisted of a warm-up (5 minutes), resistance training (25 minutes), balance exercises (10

minutes), and the dance video gaming (20 minutes).

The progressive resistance training focused on the muscle groups of the core and

lower extremities that are used in the functional activities of daily living, such as walking,

standing up from a chair, sitting down, or stair climbing. The goal of each session was to

perform two sets of ten to 15 repetitions of each exercise in a slow, controlled manner,

with a one minute sitting break after each set and between the series. Training intensity

was controlled by perceived exertion and intensity between "somewhat hard" and "hard

(heavy)" on Borg's perceived exertion scale. This corresponds to a point of instantaneous

Chapter Four

92

muscular fatigue at the end of a certain exercise [25]. To maintain the intensity of the

stimulus during the training period, the number of repetitions and the load were

progressively increased with weight vests (Kettler GmbH & Co KG, D-59469 Ense-Parsit), as

tolerated by the participants. The weight of the vests was adjusted with single sand-filled

elements of 1.125 kg each.

The progressive postural balance program consisted of static and dynamic functional

balance exercises [26]. Participants' balance skills were challenged through a variety of

activities performed with the help of air-filled balance cushions (diameter 32 cm and 16

cm) and grip balls (diameter 12 cm) (Ledraplastic S.p.a, I-33010 Osoppo).

Figure 4. 1 Dance video game: (a) participant on the dance pad secured by ropes fixed on the ceiling; (b–d) screenshots of the dance video game

The dance video game was performed on metal dance pads (Figure 4.1 a) (TX 6000


93

Metal DDR Platinum Pro, 93 × 14.7 × 109 cm, Mayflash Limited, Baoan Shenzhen, China)

with a specially designed modifycation of the StepMania (Version 3.9) software [17]. The

dance pad was connected to a desktop computer using USB. The video game was then

projected on a white wall with a beamer. A scrolling display of arrows moving upwards

across the screen cued each move, and the participants were asked to execute the

indicated steps (forward, backward, right, or left) when the arrows reached the fixed raster

graphic at the top of the screen (Figure 4.1 b–d) and in time with different songs (32 to

137 beats per minute). In the first training session, a tutorial sequence was provided to

ensure understanding of the task. As the levels increased, additional distracting visual

cues, e.g., "bombs," were presented (Figure 4.1 c). Participants had to ignore these cues

and keep their attention focused on the arrows. Occasionally, some arrows were drawn-

out on the target locations, indicating that the trainees should remain for a while on the

dance pad button on one leg (Figure 4.1 d). The arrow sequences were generated using

the Dancing Monkey MATLAB script [27]. Electronic sensors in the dance pad detected

position and timing information that was then used to provide participants with real-time

visual feedback. For each training session, the participants performed for four songs of 2

to 3 minutes length each, with a short break of 30 seconds after each song. Progression of

performance was controlled through the beats per minute and the difficulty level.

When an exercise required the participants to stand, they were secured with ropes

fixed on the ceiling, which they could hold on to (Redcord AS, Staubo, Norway).

4.2.3. Usual care

The participants in the CG did not participate in the cognitive-motor program, but were

able to participate in the leisure time programs offered at the care homes at their own

will. These programs were non-specific, not targeted toward specific exercise goals, and

were representative of what is usually offered in assisted-living facilities [28]. Table 4.1

provides information regarding the physical activities of the CG during the intervention

period.

Chapter Four

94

Table 4.1 Physical activities of the control group during intervention

Participant Activity Duration (minutes)/frequency

1 WalkingSocial dancing

30–60/daily120/weekly

2 WalkingExercise program at care home*

60/daily45/irregularly


90/weekly45/irregularly

4 WalkingAqua gym

45/daily45/weekly


90/daily45/weekly

6 No activities -

Notes: * Exercise program at the care home: Exercise is conducted seated or/and in a standing position. Trained factors are flexibility, coordination of movements, strength, endurance, fine and gross motor skills, posture and memory.

4.2.4. Voluntary step execution

To estimate the performance of voluntary step execution, a test protocol was adopted that is able

to identify elderly individuals at risk for falls under attention-demanding conditions [29,32]. The

protocol assesses the change in the speed of voluntary step execution under the influence of a

secondary distractive cognitive task and the time to initiate and complete a step [7,8,24]. The test

was performed with all participants one week before and one week after the twelve-week training

period.

For the test, subjects stood upright on a force platform with feet abducted 10°, barefoot, and

heels separated medio-laterally by 6 cm. The stepping task required the execution of a step forward,

backward, or to the side as quickly as possible after a tap cue on the heel, which was provided by the

investigator with a cushioned hammer. The tap cue resembles the cutaneous stimulus experienced

by the foot when hitting an object prior to stumbling or tripping [29]. Six trials for each step direction

were recorded under single task and dual task conditions for a total of 36 trials. Step execution trials

always occurred with the dominant leg, as chosen by the subject. Two target force platforms were

used in front of (for forward steps) or behind (for backward steps) the main platform in order to

register the data from the landing of the moving leg (Figure 4.2 a). The force platforms (Kistler AG,


95

(b)

(a)

Foot o�

Foot contact

Fy [N

]C

OP

x [m

m]

Fz [N

]

100

-100

0

-200

200

-200

0

400

600

50

-50

0

-100

100

Time [Seconds]

Tap cue

0

0

0

0.5 1.0

0.5 1.0

1.00.5

Initiation

swing leg

target forceplatform

zy

x

zy

x

Figure 4.2 Voluntary step execution test: (a) participant standing on the force platform and executing a backward step after tap cue on the heel by the supervisor; (b) example of force platform data for a single step to determine the occurrence of the step parameters. Abbreviations: COPx, medio-lateral deviation of body‘s center of pressure in millimeters; Fy, anterior-posterior ground force in Newton; Fz, vertical ground force in Newton.

Chapter Four

96

Switzerland, 400 × 600 mm) collected the ground reaction force data at a frequency of 2000 Hz.

In the single task condition, subjects focused on a white cross displayed at eye-level on

a black screen at a distance of 4.60 meters in front of them. Under dual task conditions, a

Stroop Color-Word task was displayed [30,31]. Participants were instructed to read the ink

color of the displayed words out loud. The performance of the participants was controlled

and corrected by the investigator if needed, but was not recorded as the Stroop Color-

Word task was used only for distractive purposes.

4.2.5. Data and statistical analysis

The criteria for success of this pilot was based on the primary feasibility objective

(adherence to the exercise plan), and methodological standards for being adherent to

training. A 75% attendance rate for the training sessions was set as the definition for being

adherent to the training program [34]. A total of 24 training sessions was scheduled for

each individual in the IG.

Force platform data was analyzed with a program written in MATLAB R2011a (Math

Works Inc., Cambridge, MA) to identify the following time points for each trial: tap cue,

response initiation (INI), foot off, and foot contact (Figure 4.2 b). These time points relate

to the definitions provided by Melzer et al [32,35]. Tap cue on the heel was detected as

a spike greater than three standard deviations from the average baseline noise in the

anterior-posterior direction of the ground force data. INI was defined as the first medio-

lateral deviation of center of pressure toward the stance leg (greater than 4 mm away from

the average baseline noise after the tap cue). Foot off was defined as a sudden change

of the center of pressure slope toward the stance leg in the medio-lateral direction. Foot

contact corresponds to the time when loading of the vertical ground reaction force on the

target force platform reaches more than 1% of a subject's body weight.

Statistical computations were carried out with SPSS 19 for a per-protocol strategy of

analysis in which only those subjects who adhered to the training counted toward the final

results. An average value for each temporal parameter in each stepping direction and for

both task conditions (single task and dual task) was calculated. A comparison at baseline


97

was undertaken using a Mann-Whitney U test and a chi-squared test for dichotomous

variables. Due to non-normality of the data, a Mann-Whitney U test was used to estimate

group interaction effects in the form of between-groups differences, i.e., IG and CG after

the twelve-week time period. For this purpose, the difference of the values pre and post

intervention for each subject were calculated and then compared. The effect size, r, was

calculated as r = Z/√N (where Z is the approximation of the observed difference in terms of

the standard normal distribution and N is the total number of samples; r = 0.1, small effect;

r = 0.3, medium effect; and r = 0.5, large effect). A Wilcoxon signed rank test was used to

compare inner-group pre/post data. The significance level was set at p ≤ 0.05. A trend to

significance was defined as 0.10 ≤ p > 0.05.

Table 4.2 Demographic baseline data of participants

Group Intervention group Control group

No of participants 9 6

Age (mean, SD) 83.6, 3.4 86.2, 4.8

Sex (female/male) 6/3 3/3

Height in cm (mean, SD) 160.3, 9.9 160.9, 9.4

Weight in kg (mean, SD) 68.0, 17.5 65.5, 9.4

Mini-mental statusa (median, range) 28, 27–30 25.2, 22–29

Walking assistance

None/cane or crutches 5/4 5/1

Number of falls in the last 6 monthsb

None 7 4

One 1 1

>One 1 1

Diabetes 0 1

Hypertension 2 3

Cardiac insufficiency 3 1

Arthropathy 5 1

Osteoporosis 4 2

Notes: a Minimum score = 0, maximum score = 30 (higher scores indicate better functioning); b A fall was defined as an event, which results in a person coming to rest on the ground or other lower level [33]Abbreviation: SD, standard deviation

Chapter Four

98

4.3 Results

A flow chart (Figure 4.3) provides detailed information on the subjects included in

this study and on the subjects lost during the intervention phase. Demographic

data is summarized in Table 4.2. The participants were willing to be randomized.

Neither subjective nor objective side effects related to the used intervention were

reported. There were no significant differences at baseline in either demographic

data or temporal measurements of the voluntary step execution test between the

groups.

The average exercise program compliance was 86.9% (20.8 out of 24 sessions).

Two participants achieved a compliance of only 71% (17 out of 24) and 42% (10 out

of 24), respectively. As we expected the participants to attend at least 75% of the

exercise sessions, they were not considered for the analyses.

Temporal data of the voluntary step execution task is summarized in Table

4.3. Compared to the baseline data, the IG showed an overall time reduction of

-17.9% in all assessed temporal parameters after the training program (single task

condition: -15.7%; dual task condition: -20.1%). In comparison, the CG showed

an increase in time of +1.3% in all assessed temporal parameters (single task

condition: +1.5%; dual task condition: -4.1%). Data for the dual task condition

showed longer times for each of the three examined temporal parameters under

dual task conditions compared to single task conditions for all step directions in

both groups (IG: +42.7%; CG: +30.0%).

Between-group comparison revealed significant differences for INI of forward

steps under dual task conditions (U = 9, p = 0.034, r = 0.55) and for backward steps

under dual task conditions (U = 10, p = 0.045, r = 0.52) in favor of the IG.

Inner-group comparisons resulted in step directions with significance and step

directions with a trend to significance in pre/post-differences in the IG for INI, foot

off, and foot contact (Table 4.3). There were no changes detectable for the CG for

the inner-group comparisons.


99

Asse

ssed

for e

ligib

ility

(n =

30)

Excl

uded

(n =

5)

• No

t mee

ting

incl

usio

n cr

iteria

(n =

2)

• De

clin

ed to

par

ticip

ate

(n =

3)

Com

plet

e da

ta se

ts (n

= 6

)

Rand

omiz

ed (n

= 2

5)

Allo

cate

d to

inte

rven

tion

grou

p (n

= 1

4)• R

ecei

ved

allo

cate

d in

terv

entio

n (n

= 1

1)• D

id n

ot re

ceiv

e fu

ll al

loca

ted

inte

rven

tion

(n =

-3)

beca

use

felt

asha

med

by

play

ing

the

com

pute

rga

me

(-1)

no

stud

y co

mpl

ianc

e (<

75%

) (-2

)

Allo

cate

d to

cont

rol g

roup

(n =

11)

Loss

es fo

r tes

ts (n

= -5

)Re

ason

s: to

o fra

il (-

1), i

njur

y du

e to

a fa

ll (-

1), p

erso

nal o

blig

atio

ns (-

3)

Com

plet

e da

ta se

ts (n

= 9

)

Loss

es fo

r tes

ts (n

= -2

)Re

ason

s: in

jury

due

to a

fall

(-2)

Figu

re 4.

3 The

stud

y flow

char

t

Chapter Four

100

Tabl

e 4.3

Tem

pora

l dat

a in s

econ

ds an

d sta

tistic

al ev

aluat

ion of

the v

olunt

ary s

tep e

xecu

tion t

est

r 0.03

0.55’’

0.12

0.27

0.27

0.18

Foot

off

0.30

0.24

0.09

0.37’

0.30’

0.00

Foot

cont

act

0.37’

0.24

0.18

0.52’’

0.15

0.03

Notes

: Valu

es ar

e in s

econ

ds an

d disp

layed

as gr

oup m

edian

s with

inte

rqua

rtile

rang

es (q

1; q3

) due

to no

n-no

rmal

distri

butio

n of d

ata.

* Sign

ifica

nt in

ner-g

roup

diffe

renc

es pr

e-po

st (p

inner

≤ 0.

05) c

alcula

ted w

ith W

ilcox

on si

gned

rank

te

st; ° T

rend

to si

gnifi

canc

e (p inn

er ≤

0.10

); +

Sign

ifica

nt be

twee

n-gr

oup d

iffer

ence

s afte

r inte

rven

tion p

hase

(pbe

twee

n ≤ 0.

05) c

alcula

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101

4.4 Discussion

The present pilot study aimed to develop and test a multimodal exercise intervention

and to deliver it to individuals living in care homes. The main focus was to evaluate the

feasibility of the multimodal intervention as a whole and the ability to recruit and retain

elderly subjects, as well as to assess the effects of the intervention. This study showed

that a cognitive-motor training program containing strength, balance, and computerized

cognitive training components is feasible and is able to improve voluntary step execution

under single task and dual task test conditions in older adults living in care homes. We

demonstrated the feasibility of acquiring acceptable compliance rates for care home

dwelling older people randomized to control and experimental training groups.

Our target of 75% compliance for this 12-week pilot project was attained. Two

individuals had a less than 75% attendance rate and were considered non-compliant

for the training. This non-compliance was mainly attributable to permanent sickness

and low motivation that prevented program adherence. Thus, compliance with the

exercise interventions and retesting was excellent. Adherence for group-based exercises

could be expected to be between 72% and 88% [34]. Our intervention is in the higher

range of adherence for group-based exercise. However, where we report on values after

three training months, Nyman and Victor [34] report values that may be expected by 12

months. In a future phase III trial, the follow-up period for the assessment of adherence

and attrition should, therefore, preferably be extended to a similar time frame to facilitate

comparability of this future study with reference values.

To our knowledge this is the first intervention study that demonstrates temporal

improvements in voluntary step execution under dual task conditions in older adults.

This study confirms previous findings that showed improvements in dual task motor

performance after an exercise program that included additional dance video gaming [17].

Although in previous literature, the deficiency of older adults in making rapid voluntary

steps under dual task conditions is well documented, there is still a lack of studies aiming

to improve the performance of voluntary step execution of older adults, specifically

under attention-demanding circumstances. The deficiency of coping with attention-

Chapter Four

102

demanding situations is well illustrated by the temporal delay of step execution in the

dual task condition of the voluntary step execution test used in this study. In line with

previous reports [29], we observed a temporal delay in step responses for all participants,

regardless of group allocation, under the influence of a concurrent cognitive task.

In the dance video game, subjects were expected to observe the virtual environment

for drifting arrows and initiate dance steps at the same time. When using an outward step,

participants needed to rapidly unload the leg they were falling toward to allow them

to take a step. This may be challenging from a cognitive, reaction time, and/or muscle

power generation perspective [36]. The crucial point is that dance video gaming not only

requires well-coordinated leg movements, but also requires cognitive work, e.g., sensing

of stimuli, paying attention, and making quick decisions [14].

The fact that this intervention had an impact on the initiation of the step response is

important since step or gait initiation is frequently repeated during daily activities, leading

to accidental falls during the step initiation phase in people with deficits in balance control

[37]. Important mechanisms for step initiation are the anticipatory postural adjustments

(APAs). The function of APAs is to prepare the body for the imminent movement and

possible changes in balance as a direct result of the movement caused by moving the

body center of mass toward the stance limb [38]. Falls during initiation of a step could

occur when the APAs are not performed efficiently enough prior to the unloading of the

swing leg, causing an unstable postural condition [4]. These mechanisms are complex and

require efficient peripheral sensory detection and afferent nerve conduction, followed by

central neural processing and efferent nerve conduction [29,39]. It is hypothesized that

these mechanisms are repeatedly trained by the use of a dance video game. Every step

on a dance pad has to be planned and executed with the proper timing while focusing

attention on the arrows on the screen.

Since our dance video game was based on the correct timing of the steps and not

on the maximal speed generation of the leg, we hypothesized that improvements in

step execution would be accountable in large part to the more efficient intramuscular

interplay, induced as well by the strength and balance training. The finding that a large


103

part of the improvements in voluntary step execution seems to be attributable to the

earlier execution of APA movements during the initiation phase was somewhat surprising.

This leads to the question of whether the improvements we observed are attributable

to peripheral or to central adaptations. It is known that the supplementary motor area

contributes to the timing of the APAs during step initiation [40]. It would be interesting to

examine whether our cognitive-motor intervention has an influence on the activity of the

supplementary motor area in a future study to clarify this observation.

4.4.1. Related work

There are some reports on the use and effects of similar virtual reality training in various

populations. Methods using immersive computer technologies resulted in improved

motor functions of the upper extremities and a cortical activation after virtual reality

intervention in patients with chronic stroke [41]. Older adults benefited from training

in terms of improved functional abilities, postural control, and simple auditory reaction

times under dual task conditions [42]. Functional balance and dual task reaction times

in older adults are improved by virtual reality and biofeedback training. A virtual

rehabilitation program with the help of a semi-immersive virtual reality workbench,

in a non-hospital environment, resulted in qualitatively improved manual trajectories

and increased movement velocity of the trained upper extremities for patients with

stroke, but without any transfer to real-life activities [43]. A virtual reality based

treadmill intervention conducted by Yang et al [44] showed improved walking speed

and walking ability at post-training in patients with stroke. Preliminary evidence for

clinical effectiveness of virtual reality obstacle training post stroke has been reported

by Jaffe et al [45].

Although it seems more intuitive that more immersive virtual environments are to

be preferred for motor training, this may not actually be the case [46]. Less immersive

desktop or wall screen displays can be used for this purpose as well [14] and have

the advantage that no studies that used these two dimensional displays have been

associated with incidence of cyber-sickness [46].

Chapter Four

104

4.4.2. Limitations

Several limitations of this work should be discussed. Surely the fact that step direction and

the swing leg in the voluntary step execution test were known prior to the step execution

could possibly have influenced the initiation of the step. An impact on the generation of

APAs cannot be excluded since the subjects may try to lean on the supporting leg prior

to the tap cue. However, the subjects of the CG had the same conditions and showed

different reactions. Furthermore, we attempted to control for this potential disruptive

factor through careful observation of the center of pressure on the verge of the tap cue.

The point of application of the tap cue itself might be a limitation of the assessment

protocol. A trip stimulus under real life conditions would be expected on the front of the

foot and not the heel, and therefore, giving tap cues on the foot front might result in

different reactions. Another limitation was the rather small sample size.

This pilot study, therefore, only reveals first estimates for the measures of a consecutive

phase III study. This is an inherent property of a pilot study, and our findings warrant

further research in a larger phase III main study that includes a larger sample and clinically

relevant outcome measures. Differences regarding training intensities between the

groups were another limitation. Future studies with larger sample sizes are needed, which

compare training groups that achieve similar amounts of strength and balance training

and where one group receives additional game-like training. For a more substantial study,

monitoring the occurrence of falls post intervention is also recommended.

4.4.3. Future directions

The IG trained 60 minutes twice weekly for 12 weeks and the CG received the usual care. It

was thus expected that we would observe a difference in the development between the

two groups since it seemed obvious that the difference in the amount of training would

be the explanatory factor for the observed differences in the voluntary step execution

test. We did not expect an effect for usual care because it did not comply with training

recommendations to improve physical functions to prevent falls in the elderly [47].

Therefore, future studies should compare training groups that achieve similar amounts


105

of strength and balance training, where the intervention group receives an additional

computerized cognitive component and the control group a placebo. In this case, we

expect, however, only marginal effects on voluntary step performance under dual task

conditions from the control group. The results of previous studies with similar groups

that performed progressive, machine-driven, resistance training complemented with

functional balance exercises revealed no improvement of performance under attention-

demanding circumstances [48,49].

In future studies, to clarify the additional influence of the dance video game on the

subjects in the IG, we should consider a study design with a control group that would

perform the strength and balance exercises without the additional dance video gaming.

Currently, we are performing such a trial registered under ISRCTN05350123 (www.

controlled-trials.com). In this study, however, we wanted to demonstrate the "proof of

concept" of the effect of a cognitive-motor intervention compared to usual care in care

homes in a pilot study.

4.5. Conclusion

We conclude that pilot studies with explicit feasibility objectives are important foundation

steps in preparing for large trials. Ongoing formal review of the multifaceted issues

inherent in the design and conduct of pilot studies can provide invaluable feasibility and

scientific data for rehabilitation specialists, e.g., physiotherapists, and may also be highly

relevant for furthering the development of theory based rehabilitation. For older

adults, the ability to take a quick step to prevent a fall is crucial, especially under

attention-demanding circumstances. We could demonstrate that a cognitive-motor

intervention based on strength and balance exercises with the addition of dance

video gaming is able to improve voluntary step execution under both single and dual

task conditions in older adults. The trainees were able to quicken step initiation and

total step completion time.

This study may constitute a reference for further studies in the topic of fall

prevention in older adults with the aim to improve physical performance under dual

Chapter Four

106

task conditions. This study encourages the further development of this intervention,

preferably with a randomized control design and a larger sample. The application in

a main study is deemed feasible with no need for protocol modifications.

Acknowledgments

A special thank goes to Turgut Gülay, research assistant at the Institute of Biomechanics,

for the assistance during the voluntary step execution test. We would also like to thank

Angela Naegeli and Amos Coppe for supervising the training program and Eva van het

Reve and Andrea Schärli for their help during the voluntary step execution test.

Authors' contributions

Conception and design: GP, EDdB, AC; manuscript drafting: GP, EDdB; critical revision of

manuscript for its content and approval of final version: GP, EDdB, AC, SL, KM.

Disclosure

The authors report no conflicts of interest in this work.


107

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Five

A cognitive-motor intervention using a dance video game to enhance foot

placement accuracy and gait under dual task conditions in older adults:

a randomized controlled trialPichierri G1, Murer K1, de Bruin ED1

1Department Health Sciences and Technology (D-HEST),

Institute of Human Movement Sciences and Sport, ETH Zurich, Switzerland

published in BMC Geriatrics 2012, 12:74 (www.biomedcentral.com/1471-2318/12/74)

Ch

ap

ter

Chapter Five

114

Abstract

Background: Computer-based interventions have demonstrated consistent positive effects

on various physical abilities in older adults. This study aims to compare two training groups

that achieve similar amounts of strength and balance exercise where one group receives

an intervention that includes additional dance video gaming. The aim is to investigate the

different effects of the training programs on physical and psychological parameters in older

adults.

Methods: Thirty-one participants (mean age ± SD: 86.2 ± 4.6 years), residents of two Swiss

hostels for the aged, were randomly assigned to either the dance group (n = 15) or the control

group (n = 16). The dance group absolved a twelve-week cognitive-motor exercise program

twice weekly that comprised progressive strength and balance training supplemented

with additional dance video gaming. The control group performed only the strength and

balance exercises during this period. Outcome measures were foot placement accuracy, gait

performance under single and dual task conditions, and falls efficacy.

Results: After the intervention between-group comparison revealed significant differences for

gait velocity (U = 26, p = 0.041, r = 0.45) and for single support time (U = 24, p = 0.029, r = 0.48)

during the fast walking dual task condition in favor of the dance group. No significant between-

group differences were observed either in the foot placement accuracy test or in falls efficacy.

Conclusions: There was a significant interaction in favor of the dance video game group for

improvements in step time. Significant improved fast walking performance under dual task

conditions (velocity, double support time, step length) was observed for the dance video game

group only. These findings suggest that in older adults a cognitive-motor intervention may result in

more improved gait under dual task conditions in comparison to a traditional strength and balance

exercise program.

Trial registration: This trial has been registered under ISRCTN05350123 (www.controlled-

trials.com)

Keywords: dual task, dance video game, gait, older adults, cognitive-motor intervention

Foot placement accuracy and gait

115

5.1. Background

In the growing population of older people falling is a common problem. Approximately

30% of older adults over 65 years of age, experience a fall each year [1–3]. Fall incidence is

even higher (50%) in women aged 85 and above [4]. Individuals who require more time to

initiate and execute a step to avoid a threat or to recover postural balance, either during

walking or performing postural transitions, may be at greater risk for falling [5]. Similarly,

variable spatio-temporal gait characteristics may increase this risk [2]. For safe walking

the accuracy with which one places the foot on the walking surface is essential, especially

in challenging environments. Decreased foot placement accuracy [6,7] together with an

increased variability in spatio-temporal gait characteristics [8], and dual task deficits [9] are

typical symptoms of the ageing process and constitute critical factors that compromise

safe walking [10].

Common tasks of daily life such as walking are dependent on both sensorimotor

processes and higher-level cognitive functions [9]. Thus, the accurate foot placement

onto a footpath for instance, requires not only the appropriate planning and execution of

the movement. It also requires visual scanning, the extraction of visual information from

the environment, and cognitive skills related to so-called executive functioning processes

[7,11,12]. The term executive functioning processes refers to a group of cognitive actions

that include: dealing with novelty, planning and implementing strategies for performance,

using feedback to adjust future responding, vigilance, and inhibiting task-irrelevant

information [13]. There also is increasing evidence that an age-related decline in visuo-

motor control contributes to deficiencies in foot placement control [14]. Suboptimal visual

sampling strategies have been observed in older adults prone to falling when taught to

step into a target location [7,14,15].

Exercise interventions that incorporate exercises to improve muscle strength and

postural control have been often recommended for older adults [16]. However, with

physical exercise alone the additional cognitive requirements of safe walking cannot be

addressed. Two recent reviews discussed the interplay between physical functions and

cognition [17,18]. Both brought out the importance to combine physical and cognitive

Chapter Five

116

training into clinical practice to enable older adults to move safer in their physical

environment. Especially computerized interventions seem to be promising for this

purpose [17]. Thus, cognitive elements should be taken into account when designing an

exercise regimen with the aim to preserve or improve walking skills in older adults [19,20].

Interventions should thereby focus on executive functioning processes [19], in particular

on divided attention [21], and should provide physical activities with decision-making

opportunities because these are believed to be able to facilitate the development of both

physical performance and brain functions [22].

A simple and motivating way to incorporate a cognitive element into a physical exercise

program is the use of interactive video games. Interactive video games seem to have the

potential to train cognitive functions [23] such as executive functioning processes [24].

An interactive dance video game for example [25–27], requires the player to observe

the virtual environment for drifting cues and to concurrently execute well-coordinated

body movements, thus, challenging in particular divided attention skills. Previous dance

video games studies have shown the feasibility, defined through recruitment, attrition

and adherence to the exercise intervention [28], of this approach. Dance video games

studies in senior living settings [26,27,29,30] or with post-menopausal women [31] have

also shown that this approach is a safe, low-cost and motivating way to activate and

ensure continuation of physical exercise in middle-aged and older adults. Further, positive

contributions to self-reported balance confidence and mental health were observed

[26,29].

The results of two pilot studies conducted in care home settings, have shown that

the addition of dance video gaming may have a positive effect on relative dual task

costs of walking [30] and gait initiation under attention-demanding circumstances [27]

even in the oldest old (85 years and beyond). These latter two findings, however, should

be interpreted with caution. In both studies the control group did not train but rather

underwent usual care. To clarify the additional influence of the dance video game we

should consider a study design with a control group performing the same strength and

balance exercises, however, without the additional dance video gaming [27].


117

This study compares two training groups that achieve similar amounts of physical

strength and balance exercise, where one group additionally performs dance video game

training. The aim is to investigate the additional effects of the dance video game training

on foot placement accuracy [7,15], gait under single and dual task conditions, and on fear

of falling.

5.2. Methods

5.2.1. Participants

The study was designed as a prospective randomized controlled trial (ISRCTN05350123)

and was carried out from June to September 2011. Participants were recruited from two

hostels for the aged in the Canton of Zurich, Switzerland. The study protocol was approved

by the local ethics committee (KEK-ZH-NR 2011-0005/0). All measurements and trainings

were performed in suitable locations at the hostels.

The residents of both hostels were invited to attend an information session. Thirty-five

(67.3%) out of 52 persons were interested in participating and were assessed for eligibility.

Participants were included if they were older than 65 years, had a score of at least 22 points

on the Mini-Mental State Examination (MMSE) [32], were able to walk for at least eight

meters with or without the need for a walking aid, and were free of rapidly progressive or

terminal illness, acute illness or unstable chronic illness. If unsure, subjects were asked to

consult their primary care physician for medical clearance. They were excluded if a severe

impairment of vision would impede to see projections on a wall screen as needed for the

intervention.

Four interested persons were excluded from the study before the randomization process. One

person changed his mind and declined to participate due to insufficient motivation. One person

suffered from hernia inguinalis before the start of the study and two other persons were excluded

for not fulfilling the inclusion criteria (MMSE < 22). A total of 31 (59.6%) eligible residents signed

informed consent statements and were randomly assigned to either the ‘Dance group‘ (DG, n =

15) or the ‘Control group‘ (CG, n = 16) using a random numbers table. Blinding of investigators

was not possible because the investigators supervised and conducted the training sessions.

Chapter Five

118

5.2.2. Intervention

The DG and the CG underwent a twice-weekly physical exercise program consisting of

progressive resistance and postural balance training for twelve weeks. Intensity and

duration of the program were chosen based on the guidelines published by the American

College of Sports Medicine [33,34] and on a review by Paterson et al. describing exercise

recommendations for older adults [35]. Training sessions were conducted in groups

of three or four participants to form group cohesion and to encourage exercise class

participation [36]. A training session lasted on average 40 minutes and consisted of a

warm-up (5 minutes), resistance training (25 minutes), and balance exercises (10 minutes).

In addition to the physical exercise program the DG performed a progressive video game

dancing program for 10-15 minutes throughout the study (‘cognitive-motor program‘).

When exercises required the participants to stand, they were requested to hold on to ropes

fixed on the ceiling for safety reasons (Figures 5.1 and 5.2) (Redcord AS, Staubo, Norway).

a b c

weight west

Redcords

air-filled cushion

Figure 5. 1 Exercise examples from the physical exercise program: strength exercises (a) sit-to-stand, (b) squat; (c) balance exercise: subject rolls the ball back and forth or from the left to the right with the left foot while balancing on the air-filled cushion.


119

5.2.3. Physical exercise

The progressive resistance training focused on the muscle groups of the core and lower

extremities that are used in functional activities of daily living (Figure 5.1 a–b). Two sets

of ten to 15 repetitions of each exercise in a slow, controlled manner were performed.

One minute sitting breaks after each set and between the series were provided. Training

intensity was controlled by perceived exertion and intensity between „somewhat hard“

and „hard (heavy)“ on Borg‘s perceived exertion scale [37]. To maintain the intensity of

the stimulus during the training period, the number of repetitions and the load were

progressively increased with weight vests (Kettler GmbH & Co. KG, D-59469 Ense-Parsit),

as tolerated by the participants.

The progressive postural balance program (Figure 5.1 c) consisted of static and

dynamic functional balance exercises using air-filled cushions and grip balls (Ledraplastic

S.p.a, I- 33010 Osoppo) [38]. A more detailed description of the program can be found

elsewhere [38].

5.2.4. Cognitive-motor program

As an additional cognitive element the DG performed the dance video game after

the physical exercise in every training session. The dance video game was performed

on metal dance pads (Figure 5.2 a) (TX 6000 Metal DDR Platinum Pro, 93 x 14.7 x

109 cm, Mayflash Limited, Baoan Shenzhen, China) and with a specially designed

modification of the StepMania (Version 3.9) free-ware [27,30]. The dance video game

screen was projected on a white wall. A scrolling display of arrows moving upwards

across the screen cued each move, and the participants were asked to execute the

indicated steps (forward, backward, right, or left) when the arrows reached the fixed

raster graphic at the top of the screen (Figure 5.2 b–d), and in time with different

songs (32 to 137 beats per minute). In the first training session a tutorial sequence

was provided to ensure understanding of the task. As the levels increased additional

distracting visual cues, e.g., „bombs,“ were presented (Figure 5.2 c). Participants had

to ignore these cues and keep their attention focused on the arrows. Occasionally,

Chapter Five

120

some arrows were drawn-out on the target locations indicating that the trainees

should remain for a while on the dance pad button on one leg (Figure 5.2 d). The arrow

sequences were generated using the Dancing Monkey MATLAB script [39]. Electronic

sensors in the dance pad detected position and timing information that was then

used to provide participants with real-time visual feedback. For each training session,

the participants performed for four songs of two to three minutes length each, with a

short break of 30 seconds after each song. Progression of performance was controlled

through the beats per minute and the difficulty level.

Figure 5. 2 Dance video game: (a) participant on the dance pad secured by ropes fixed on the ceiling; (b–d) screenshots of the dance video game


121

5.2.5. Baseline assessments of vision

To ensure that participants were free of vision impairments, which would have complicated

the performance of the video game dancing part, participants‘ vision skills were assessed

with the vision tests of the ‘Physiological Profile Assessment‘ (PPA) [40,41]. Tests of edge

contrast sensitivity (‘Melbourne Edge Test‘), and binocular dual-contrast visual acuity,

were considered for assessing vision.

5.2.6. Test procedures and outcomes

The following tests were performed in the week before and in the week after the twelve

weeks training period in suitable locations at the hostels.

5.2.6.1. Foot placement accuracy test

Foot placement accuracy (FPA) was assessed with an adapted version of the protocol

described by Chapman and Hollands in 2007 [7]. Subjects were instructed to walk at

self-selected walking speed along a path with three different walking conditions:

‘Condition 1‘ required placing the right foot into Target 1 (T1) (Figure 5.3 a); in ‘Condition

2‘ subjects placed the right foot into T1 and the left foot into Target 2 (T2) (Figure 5.3 b);

‘Condition 3‘ additionally required stepping over an obstacle placed between the two

targets (Figure 5.3 c). The targets and the obstacle were made of soft foam material. The

targets were rectangular (target area: 190 mm x 415 mm) and comprised a raised border

(40 mm x 40 mm x 40 mm). Dimensions of the obstacle were 170 mm x 670 mm x 25 mm

(height x length x depth). 170 mm corresponds to the ideal height of a staircase step as

defined by the Federal Authorities of the Swiss Confederation. The subjects performed

ten repetitions for each of the three walking conditions, resulting in a total of 30 trials

per person. To prevent task familiarization within each condition, the target(s) appeared

in two possible positions separated medio-laterally by 8 cm (Figure 5.3 d), an adaptation

to the protocol based on the results of Young and Hollands [15]. Prior to the start of

each trial subjects stood with their back against the walking path facing a wall to limit the

amount of attention towards the pathway during the adjustments of the target position

Chapter Five

122

by the investigator. After a light cue, triggered by the investigator, subjects turned towards

the walking path and began to walk from a labeled starting position over the path at

a self-selected pace. Subjects were verbally instructed prior to each change of walking

condition to place their foot as accurately as possible in the middle of the target area

and were allowed to perform two rehearsal walks for each condition. The presentation

of the target positions was randomized and of equal number for each condition. The

presentation of the walking conditions was not randomized.

To assess participants‘ foot placement performance into the targets, adhesive

labels were placed on both shoes on calcaneus level for anterior-posterior (A-P)

distance assessment and on the level of the head of the fifth metatarsal for medio-

lateral (M-L) assessment (Figure 5.3 e). During each trial the targets were recorded by

two stationary video cameras (Contour HD 1080p) at a sampling rate of 30 Hz. A fixed

image of the foot‘s stance phase into the target was then read into the analyzing

software (Vicon Motus 9.2, Vicon Motion Systems, Oxford, UK). The foam targets were

previously marked with two triangles (Figure 5.3 e), serving as calibration points to

read in the dimensions and to determine spatial orientation of the target by the video

analysis software.

The main outcome of the FPA test was the M-L and A-P deviation in mm of the

foot center to the center of the foam target. Further, walking velocity between T1

and T2 and quality aspects of the performance during the FPA test were assessed. For

the quality evaluation the number and percentage of contacts of the leading or the

subsequent foot with the target, and the use of the wrong foot were assessed.

5.2.6.2. Gait analysis

Spatio-temporal gait parameters were assessed with GAITRite® Platinum Version 4.0

software and the GAITRite® electronic walkway (CIR Systems, Havertown, USA) with

a sampling rate of 60 Hz [42–44]. The GAITRite® with an active area of 7.92 meters

length was extended with two 2.5 meters carpets at the beginning and at the end to

eliminate the effects of acceleration or deceleration and to allow for steady state gait


123

Figure 5.3 Set-up of the foot placement accuracy protocol. Subjects were required to walk along the pathway at self-selected pace and place the right foot into target 1 (Condition 1 (a)), place the right foot into target 1 and the left foot into target 2 (Condition 2 (b)), and additionally step over an obstacle lying between the two targets (Condition 3 (c)). The target(s) appeared in two possible positions separated medio-laterally by 8 cm to prevent task familiarization (d). Video still of camera 2 during stance phase used to evaluate the lateral and posterior distance error (e).

116 cm

184 cm

260 cm

a

b

c

target 1

target 2

foot marker

camera 1

camera 2

d e

light marker

midline

10cm2cm0

x

y

P = posterior distance

PL

L = lateral distance

xy

calibration point

Chapter Five

124

assessment. Subjects were instructed to walk over the electronic walkway under four different

conditions: at self- selected comfortable walking speed (normal) and at a fast walking speed

(fast, as fast as possible without running) each with or without a concurrent cognitive task

(normalcog and fastcog), respectively. The additional cognitive task consisted in counting out

loud backwards by steps of seven from a three-digit number given by the investigator at the

start of each trial. For each walking condition three trials were collected, resulting in twelve

walks per participant. Subjects were allowed to wear their everyday footwear.

The temporal-spatial parameters recorded were: velocity (cm/s), cadence (steps/min), step

time (s), cycle time (s), stance time (s), single support time (s), double support time (s), and

step length (cm). Relative dual task costs (DTC) of walking were calculated as percentage of

loss relative to the single task walking performance, according to the formula DTC [%] = 100

x (single task score – dual task score)/single task score [45]. The effective DTC changes were

defined as the mean difference between pre and post intervention (∆DTC).

5.2.6.3. Gaze behavior

ASL Mobile Eye, a head-mounted eye-tracking system (Applied Science Laboratories, Bedford,

USA) was used to assess gaze behavior during the FPA test. Based on the observation that

older adults prone to falling look away from a target location prior to heel contact on the floor

[7], the temporal-spatial gaze parameters were defined as: a) location of gaze at heel contact

(on/off target), b) the subsequent duration (milliseconds) of target fixation after heel contact,

or in case of a premature gaze shift c) the time elapsed between the early gaze shift away

from target and the heel contact (milliseconds). Gaze fixation was defined as a stabilization of

gaze in the environment for longer than 120 milliseconds [7]. The light cue, serving as a start

signal for the FPA test, was filmed by the eye-tracking camera and served as a marker for the

synchronization of the eye-tracking camera with the stationary cameras pointed towards the

targets.

5.2.6.4. Fear of falling

The Falls Efficacy Scale International (FES-I) questionnaire was used as a measure of concern


125

about falling to determine the transfer effects of training to activities of daily living [46].

5.2.6.5. Statistical methods

A 75% attendance rate for the training sessions was set as the definition for being adherent

to the training program [47]. There were a total of 24 training sessions scheduled for each

individual in the study. Only those subjects who adhered to the training counted towards the

final results (per protocol analysis).

An average value of the M-L and A-P distance errors for each walking condition and target

in the FPA test, as well as for each spatio-temporal gait parameter of the gait analysis for

each walking condition, was calculated. Due to non-normality of the data a comparison at

baseline was undertaken using a Mann-Whitney U test. The Mann-Whitney U test was also

used to estimate group interaction effects (between-groups differences), after the twelve-

week training period. For this purpose the difference of the values pre and post intervention

for each subject were calculated and then compared. The effects size, r, was calculated as r =

Z/√N (where Z is the approximation of the observed difference in terms of the standard normal

distribution and N is the total number of samples; r = 0.1, small effect; r = 0.3, medium effect;

and r = 0.5, large effect). A Wilcoxon signed rank test was used to compare within-group pre/

post data. The significance level was set at p ≤ 0.05. A trend to significance was defined as 0.05

< p ≤ 0.10. Statistical computations were carried out with SPSS 19.

5.3 Results

A total of 22 participants (mean ± SD age: 86.2 ± 4.6 years) received the full allocated

intervention. Detailed information on subjects’ recruitment and reasons for loss are

presented in the flow chart (Figure 5.4). Table 5.1 shows demographic and clinical

characteristics of the sample. Eleven (50%) subjects were classified as having a high risk for

falling based on the presence of at least four of eight possible risk factors according to di

Fabio et al. [48]. No significant differences at baseline, neither in demographic nor in the

outcome measurements, were observed between the groups. No subject manifested a

severe impairment of vision.

Chapter Five

126

An average exercise compliance of 90.6% (21.7 out of 24 sessions) was observed. The DG

showed a compliance of 94.7% (22.7 out of 24 sessions) whereas the CG visited 86.9% of the

exercise sessions (20.8 out of 24 sessions).

Figure 5.4 The Study Flow Chart

5.3.1 Foot placement accuracy

A summary of the FPA test is provided in Table 5.2. A more detailed illustration of the FPA

test data with the single target locations and conditions is provided in Table 5.3. The data of

17 participants were collected.

Between-group comparisons (all conditions and targets) resulted in no significant

differences of foot placement performance. Within-group comparison resulted in a

significant improvement in M-L foot placement performance (Z = -1.960, p = 0.05) in DG and

no changes in the CG.

The detailed results of the FPA test performance in A-P directions demonstrate an

increase in distance error for both the DG and CG. In Condition 3, for the CG even a significant

increase in A-P distance error from 8.34 to 18.75 mm was observed (Z = -2.100, p = 0.036).

Assessed for eligibility (n = 35)

Randomized (n = 31)

Allocated to Dance Group (n= 15)- Received full allocated intervention (n = 11)- Did not receive full allocated intervention (n = 4) Reasons: low exercise compliance (<75%) (n = 2), low motivation (n = 2)

Outcome Measurement: Walking (n = 11)- Losses for test: none

Outcome Measurement: Walking (n = 10)- Losses for test: (n = 1) Reason: low motivation

Outcome Measurement: Footplacement Accuracy (n = 8)- Losses for test (n = 3) Reason: reliant on walking device

Outcome Measurement: Footplacement Accuracy (n = 9)- Losses for test (n = 1) Reason: reliant on walking device

Allocated to Control Group (n= 16)- Received full allocated intervention (n = 11)- Did not receive full allocated intervention (n = 5) Reasons: low exercise compliance (<75%) (n = 2), stroke/death (n = 1), dizziness (n = 1), relocation (n = 1)

Excluded (n = 4)Reasons: Mini-Mental Status Examination Score < 22 points (n = 2), hernia inguinalis (n = 1), declined participation (n = 1)


127

Median walking velocity during the FPA test significantly increased in the DG in ‘Condition 2’

from 53.0 to 62.0 cm/s (Z = -2.371, p = 0.018), and the between-group comparison revealed

significant differences in favor of the DG (U = -2.122, p = 0.034, r = 0.51).

Table 5.1 Demographic baseline data of participants

Group Dance group Control group

No. of participants 11 11

Age (mean, SD) 86.9, 5.1 85.6, 4.2

Sex (female/male) 8/3 10/1

Height in cm (mean, SD) 159.1, 10.0 154.5, 10.1

Weight in kg (mean, SD) 68.3, 14.3 58.8, 13.1

Mini-Mental Statusa (mean, SD) 27.2, 2.0 27.0, 2.6

Vision

Vision aid (n / %) 5 / 45.4 4 / 36.4

Visual acuityb [MAR] (high / low contrast) 0.48 / 0.66 0.53 / 0.67

Melbourne Edge Testc [dB] (mode, range) 19, 9-21 19, 5-24

Fall Risk factorsd (n / %)

Low BMI (< 23) 1 / 9 5 / 4

Slow walking speed (< 1.22 m/s) 11 / 100 11 / 100

Previous falls requiring medical attention none none

Falls in the last 6 months 1 / 9 3 / 27

3 or more prescription medications 7 / 64 10 / 91

Cardiovascular medications 11 / 100 10 / 91

Anti-Anxiety medication or sedatives 3 / 27 3 / 27

Medication for dizziness none 1 / 9

Categorized as ‘Faller’ 5 / 45 6 / 55

Notes: a Minimum score = 0, maximum score = 30 (higher scores indicate better cognitive functioning); b log10 of the minimum angle resolvable (MAR) in minutes of arc (-log10 (distance (3m)/lowest correct line)); c Minimum score = 1, maximum score = 24 (higher scores indicate better edge contrast sensitivity, 1dB = -10 log10); d Di Fabio et al 2001 [48]; A fall was defined as an event, which results in a person coming to rest on the ground or other lower level. Abbreviations: SD, standard deviation; arcmin, arcminute.

Chapter Five

128

Tabl

e 5.2

Resu

lts of

foot

plac

emen

t acc

urac

y

p betw

een

0.70

0.63

0.03

*

1.00

Notes

: Dist

ance

erro

r (ab

solut

e valu

es) a

nd w

alking

veloc

ity va

lues a

re di

splay

ed as

grou

p med

ians w

ith in

terq

uarti

le ra

nges

(q1;

q3) d

ue to

non-

norm

al dis

tribu

tion o

f dat

a. * S

ignifi

cant

with

in-gr

oup d

iffer

ence

s pre

-pos

t (p wi

thin ≤

0.0

5) ca

lculat

ed w

ith W

ilcox

on si

gned

rank

test.

Perce

ntag

e valu

es ar

e defi

ned a

s the

quot

ient b

etwe

en nu

mbe

r of c

onta

cts or

wro

ng fo

ot, re

spec

tively

, divi

ded b

y the

sum

of tr

ials o

f the

who

le gr

oup.

Abbr

eviat

ions:

p with

in, p-v

alue f

or w

ithin-

grou

p com

paris

on; p

betw

een, p

-valu

e for

betw

een-

grou

ps co

mpa

rison

.

p with

in

0.44

0.17

0.81

0.10

Cont

rol g

roup

(n=

9) Post

10.1

(8.7;

15.7)

24.4

(15.5

; 30.7

)

0.49 (

0.35;

0.58)

0.41 (

0.24;

0.64)

6 (1.3

)

10 (2

.2)

16 (3

.6)

2 (0.4

)

Pre

12.9

(9.9;

16.2)

21.7

(17.2

; 26.9

)

0.53 (

0.41;

0.68)

0.33 (

0.26;

0.60)

5 (1.1

)

21 (4

.7)

14 (3

.1)

5 (1.1

)

p with

in

0.05

*

0.33

0.02

*

0.31

Danc

e gro

up (n

=8)

Post

10.1

(8.8;

11.95

)

21.2

(15.1

; 28.7

)

0.62 (

0.57;

0.75)

0.47 (

0.45;

0.49)

3 (0.8

)

8 (2.0

)

14 (3

.5)

2 (0.5

)

Pre

13.4

(10.0

; 15.3

)

16.6

(14.9

; 29.2

)

0.53 (

0.45;

0.67)

0.42 (

0.34;

0.43)

11 (2

.8)

17 (4

.3)

16 (4

.0)

2 (0.5

)

Dist

ance

erro

rs [m

m]

Med

io-lat

eral

erro

r

Ante

rior-p

oste

rior e

rror

Wal

king

velo

city [

m/s]

Cond

ition

2

Cond

ition

3

Qual

ity ev

alua

tion

(n, %

)

Cont

act w

ith le

ading

foot

med

io-lat

eral

ante

rior-p

oste

rior

Cont

act w

ith su

bseq

uent

foot

Wro

ng fo

ot


129

Tabl

e 5.3

Det

ailed

resu

lts of

foot

plac

emen

t acc

urac

y

p betw

een

0.77

0.15

1.00

0.39

0.29

0.21

0.63

0.77

0.63

0.56

Notes

: Valu

es ar

e disp

layed

as gr

oup m

edian

s with

inte

rqua

rtile

rang

es (q

1; q3

) due

to no

n-no

rmal

distri

butio

n of d

ata.

* Sign

ifica

nt w

ithin-

grou

p diff

eren

ces p

re-p

ost (

p with

in ≤ 0.

05) c

alcula

ted w

ith W

ilcox

on si

gned

rank

test;

°Tre

nd

to si

gnifi

canc

e (p wi

thin ≤

0.10

). Ab

brev

iation

s: p wi

thin, p

-valu

e for

with

in-gr

oup c

ompa

rison

; pbe

twee

n, p-v

alue f

or be

twee

n-gr

oups

com

paris

on; C

1, C2

, C3,

Cond

ition

1, 2,

and 3

; T1,

T2, T

arge

t 1 an

d 2.

p with

in

0.86

0.31

1.00

0.72

0.48

0.52

0.26

0.04

*

0.86

0.89

Cont

rol g

roup

(n=

9)

Post

10.92

(8.72

; 20.0

4)

13.71

(10.2

0; 17

.96)

8.27 (

6.78;

16.75

)

13.01

(8.37

; 2.08

)

9.16 (

6.78;

1.34)

21.40

(13.2

5; 34

.01)

23.55

(16.4

7; 30

.18)

18.75

(15.0

5; 26

.88)

24.97

(18.3

7; 31

.52)

14.97

(11.5

3; 20

.17)

Pre

12.96

(9.90

; 16.7

1)

11.72

(9.16

; 16.6

9)

11.00

(4.62

; 17.8

6)

12.52

(10.9

8; 20

.16)

9.62 (

3.16;

17.14

)

22.92

(17.2

2; 32

.28)

14.42

(10.2

1; 28

.49)

8.34 (

3.58;

23.23

)

18.60

(16.8

8; 34

.12)

19.84

(5.39

; 21.5

1)

p with

in

0.48

0.21

0.58

0.07°

0.16

0.58

0.58

0.26

0.67

0.40

Danc

e gro

up (n

=8)

Post

12.09

(8.95

; 17.6

3)

10.93

(8.92

; 12.5

2)

9.84 (

8.50;

15.09

)

9.93 (

5.65;

15.36

)

9.65 (

6.78;

10.93

)

19.59

(12.9

8; 26

.44)

22.32

(14.4

9; 31

.21)

27.86

(14.2

6; 39

.72)

21.17

(15.1

5; 26

.42)

18.52

(13.4

9; 29

.33)

Pre

15.00

(11.4

4; 17

.33)

12.27

(10.2

0; 14

.74)

10.42

(8.38

; 15.2

0)

13.51

(8.98

; 20.1

0)

12.97

(5.79

; 16.0

0)

19.82

(12.7

8; 29

.17)

17.76

(12.7

7; 29

.88)

16.80

(14.8

8; 26

.44)

22.85

(13.3

2; 28

.90)

16.56

(14.0

6; 27

.15)

Cond

ition

/Tar

get

Med

io-lat

eral

erro

r [m

m]

C1/T

1

C2/T

1

C3/T

1

C2/T

2

C3/T

2

Ante

rior-p

oste

rior e

rror [

mm

]

C1/T

1

C2/T

1

C3/T

1

C2/T

2

C3/T

2

Chapter Five

130

5.3.2 Gait analysis

The data of 21 subjects were collected for the gait analysis. The detailed results of the

spatio-temporal gait analysis are summarized in Tables 5.4 and 5.5. Significant between-

group differences where observed in the fastcog condition, where participants were

required to walk as fast as possible with a concurrent cognitive task. The DG showed a

significant increase in walking velocity (U = 26, p = 0.041, r = 0.45), and a decrease in

single support time (U = 24, p = 0.029, r = 0.48) compared to the CG. The within-group

comparison revealed significant walking performance improvements throughout all the

walking conditions for the DG. In contrast, in the CG improvements in walking performance

were only observable for the normal and normalcog conditions.

Table 5.5 summarizes the results of the DTC of walking analysis. Significant between-

group differences for ∆DTC were observed for the parameter single support time for

both normal (U = 27, p = 0.049, r = 0.43) and fast walking speed (U = 26, p = 0.041, r =

0.45). Further, in the DG the ∆DTC decreased throughout all parameters in both walking

conditions from pre to post intervention. In contrast the CG demonstrated an increase in

∆DTC values after the intervention when compared to baseline data.

5.3.3. Perceived fear of falling

The results of the FES-I questionnaire showed a reduction of concerns about falling in both

groups. In the DG the mean value (mean, SD) was lowered from 23.7 ± 6.4 to 21.8 ± 5.0 and in the

CG the mean value was reduced from 24.5 ± 4.2 to 19 ± 4.1. Between-group comparison after the

twelve-week regimen resulted in non-significant (U = 38, p = 0.134, r = 0.32) differences.

5.3.4. Gaze behavior

Substantial losses of participants for the analysis of the eye-tracking data were documented. From

the 17 participants who performed the FPA test only seven data sets were complete. Reasons for

the losses were mainly attributable to problems with the handling of the eye tracking system. For

the sake of completeness the gaze data is presented in Table 5.6 and not further referred to in

the following section.


131

Tabl

e 5.4

Resu

lts of

spat

io-te

mpo

ral g

ait an

alysis

r 0.15

0.25

0.28

0.27

0.29

0.36+

0.25

0.08

0.06

0.03

0.01

0.01

0.02

0.09

0.05

0.13

Notes

: Valu

es ar

e disp

layed

as gr

oup m

edian

s with

inte

rqua

rtile

rang

es (q

1; q3

) due

to no

n-no

rmal

distri

butio

n of d

ata.

* Sign

ifica

nt w

ithin-

grou

p diff

eren

ces p

re-p

ost (

p with

in ≤

0.05

) calc

ulate

d with

Wilc

oxon

sign

ed ra

nk te

st; ° T

rend

to

sign

ifica

nce (

p with

in ≤

0.10

), * S

ignifi

cant

betw

een-

grou

p diff

eren

ces a

fter in

terv

entio

n pha

se (p

betw

een ≤

0.05

) calc

ulate

d with

Man

n-W

hitne

y U-te

st, ° T

rend

to si

gnifi

canc

e (p be

twee

n ≤ 0.

10).

Abbr

eviat

ions:

p with

in, p-v

alue f

or in

ner-g

roup

com

paris

on; p

betw

een,

p-va

lue fo

r bet

ween

-gro

ups c

ompa

rison

; r, e

ffect

size (

r = 0.

1: sm

all ef

fect,

+r=

0.3:

med

ium ef

fect);

norm

al, se

lf-se

lecte

d walk

ing sp

eed;

fast,

fast

walki

ng.

p betw

een

0.481

0.260

0.205

0.217

0.191

0.095

°

0.259

0.725

0.778

0.888

0.972

0.972

0.944

0.669

0.804

0.549

p with

in

0.059

°

0.02

2*

0.02

2*

0.02

2*

0.03

7*

0.01

3*

0.04

7*

0.203

0.285

0.203

0.139

0.139

0.169

0.169

0.203

0.575

Cont

rol G

roup

(n=

10) Po

st

82.2

(73.8

; 101

.8)

104.2

(89.9

; 112

.3)

0.58 (

0.54;

0.67)

1.15 (

1.07;

1.34)

0.75 (

0.70;

0.92)

0.39 (

0.36;

0.43)

0.36 (

0.32;

0.49)

48.8

(46.0

; 54.9

)

114.7

(99.6

; 136

.8)

126.0

(105

.7; 13

5.7)

0.48 (

0.44;

0.57)

0.96 (

0.88;

1.13)

0.60 (

0.55;

0.74)

0.36 (

0.33;

0.38)

0.24 (

0.22;

0.34)

55.3

(50.4

; 62.6

)

Pre

69.0

(61.1

; 82.7

)

93.9

(80.2

; 99.9

)

0.64 (

0.60;

0.75)

1.28 (

1.20;

1.49)

0.86 (

0.78;

1.03)

0.43 (

0.41;

0.47)

0.44 (

0.37;

0.56)

46.6

(43.7

; 52.2

)

112.1

(99.0

; 124

.0)

118.2

(106

.0; 12

9.1)

0.51 (

0.46;

0.57)

1.02 (

0.93;

1.13)

0.65 (

0.61;

0.72)

0.38 (

0.33;

0.39)

0.30 (

0.25;

0.32)

56.0

(52.1

; 61.0

)

p with

in

0.248

0.01

6*

0.01

6*

0.01

6*

0.02

1*

0.04

1*

0.062

°

0.477

0.091

°

0.03

3*

0.05

0*

0.062

0.04

1*

0.110

0.131

0.594

Danc

e Gro

up (n

=11

) Post

88.3

(69.2

; 106

.2)

97.5

(96.0

; 111

.8)

0.62 (

0.54;

0.63)

1.23 (

1.07;

1.24)

0.78 (

0.72;

0.84)

0.41 (

0.36;

0.43)

0.37 (

0.31;

0.43)

52.7

(42.6

; 56.3

)

132.7

(93.2

; 149

.8)

127.1

(118

.2; 13

4.5)

0.47 (

0.45;

0.51)

0.94 (

0.89;

1.02)

0.60 (

0.57;

0.66)

0.35 (

0.32;

0.39)

0.26 (

0.22;

0.31)

59.2

(50.5

; 69.8

)

Pre

80.4

(72.9

; 89.1

)

95.5

(93.3

; 102

.5)

1.26 (

1.17;

1.29)

0.63 (

0.59;

0.64)

0.82 (

0.80;

0.86)

0.42 (

0.39;

0.44)

0.41 (

0.38;

0.43)

50.7

(45.7

; 53.0

)

124.7

(89.9

; 147

.4)

122.6

(113

.8; 12

8.7)

0.49 (

0.47;

0.53)

0.98 (

0.93;

1.05)

0.62 (

0.58;

071)

0.37 (

0.34;

0.38)

0.25 (

0.23,

0.33)

58.4

(53.1

; 66.7

)

Cond

ition

/Par

amet

ers

norm

al

Veloc

ity [c

m/s]

Cade

nce [

steps

/min]

Step

tim

e [s]

Cycle

tim

e [s]

Stan

ce ti

me [

s]

Single

supp

ort t

ime [

s]

Doub

le su

ppor

t tim

e [s]

Step

leng

th [c

m]

fast Ve

locity

[cm

/s]

Cade

nce [

steps

/min]

Step

tim

e [s]

Cycle

tim

e [s]

Stan

ce ti

me [

s]

Single

supp

ort t

ime [

s]

Doub

le su

ppor

t tim

e [s]

Step

leng

th [c

m]

Chapter Five

132

Tabl

e 5.4

Resu

lts of

spat

io-te

mpo

ral g

ait an

alysis

(con

tinue

d)

r 0.09

0.15

0.03

0.12

0.09

0.26

0.03

0.07

0.45+

0.42+

0.41+

0.37+

0.34+

0.48+

0.25

0.22

Notes

: Valu

es ar

e disp

layed

as gr

oup m

edian

s with

inte

rqua

rtile

rang

es (q

1; q3

) due

to no

n-no

rmal

distri

butio

n of d

ata.

* Sign

ifica

nt w

ithin-

grou

p diff

eren

ces p

re-p

ost (

p with

in ≤ 0.

05) c

alcula

ted w

ith W

ilcox

on si

gned

rank

test;

° Tre

nd

to si

gnifi

canc

e (p wi

thin

≤ 0.

10),

* Sign

ifica

nt be

twee

n-gr

oup d

iffer

ence

s afte

r inte

rven

tion p

hase

(pbe

twee

n ≤ 0.

05) c

alcula

ted w

ith M

ann-

Whit

ney U

-test,

° Tre

nd to

sign

ifica

nce (

p betw

een ≤

0.10

). Ab

brev

iation

s: p wi

thin, p

-valu

e for

inne

r-gro

up co

mpa

rison

; pbe

twee

n, p-v

alue f

or be

twee

n-gr

oups

com

paris

on; r

, effe

ct siz

e (r =

0.1:

small

effec

t, +r=

0.3:

med

ium ef

fect);

norm

al, se

lf-se

lecte

d walk

ing sp

eed;

fast,

fast

walki

ng; n

orm

al-co

g, se

lf-se

lecte

d walk

ing sp

eed w

ith ad

dition

al co

gniti

ve ta

sk; fa

stcog

, fast

walki

ng sp

eed w

ith ad

dition

al co

gniti

ve ta

sk.

p betw

een

0.673

0.481

0.888

0.573

0.672

0.228

0.888

0.751

0.04

1*

0.057

°

0.062

°

0.091

°

0.121

0.02

9*

0.260

0.324

p with

in

0.02

8*

0.139

0.074

°

0.093

°

0.059

°

0.445

0.059

°

0.059

°

0.386

0.445

0.799

0.799

0.721

0.799

0.646

0.333

Cont

rol G

roup

(n=

10) Po

st

63.2

(55.8

; 84.4

)

96.8

(74.5

; 103

.6)

0.62 (

0.58;

0.81)

1.24 (

1.16;

1.61)

0.81 (

0.79;

1.08)

0.43 (

0.38;

0.50)

0.43 (

0.39;

0.59)

46.3

(38.1

; 54.6

)

87.1

(59.0

; 103

.2)

104.1

(76.7

; 114

.1)

0.58 (

0.53;

0.78)

1.15 (

1.05;

1.57)

0.76 (

0.70;

1.03)

0.39 (

0.37;

0.50)

0.38 (

0.31;

0.51)

51.2

(38.6

; 60.0

)

Pre

60.0

(51.7

; 71.8

)

82.7

(73.9

; 100

.9)

0.73 (

0.60;

0.84)

1.46 (

1.19;

1.64)

1.00 (

0.78;

1.15)

0.46 (

0.40;

0.48)

0.55 (

0.39;

0.67)

43.4

(37.5

; 52.4

)

80.1

(61.0

; 100

.0)

91.8

(88.0

; 108

.8)

0.65 (

0.55;

0.68)

1.31 (

1.10;

1.37)

0.86 (

0.72;

0.93)

0.42 (

0.38,

0.46)

0.39 (

0.35;

0.51)

50.7

(41.2

; 57.8

)

p with

in

0.05

0*

0.02

6*

0.01

3*

0.01

3*

0.01

0*

0.01

3*

0.01

6*

0.13

1

0.01

3*

0.00

6*

0.00

6*

0.00

6*

0.00

8*

0.00

6*

0.01

3*

0.110

Danc

e Gro

up (n

=11

) Post

82.8

(60.0

; 97.9

)

101.0

(97.2

; 103

.3)

0.60 (

0.58;

0.62)

1.19 (

1.17;

1.24)

0.79 (

0.75;

0.83)

0.41 (

0.39;

0.44)

0.39 (

0.35;

0.41)

50.5

(44.3

; 56.6

)

107.5

(74.1

; 115

.6)

109.7

(101

.7; 11

7.4)

0.55 (

0.51,

0.59)

1.09 (

1.02;

1.19)

0.71 (

0.64;

0.78)

0.38 (

0.37;

0.41)

0.32 (

0.28;

0.37)

55.2

(44.8

; 62.6

)

Pre

65.4

(57.3

; 87.4

)

87.0

(82.4

, 93.8

)

0.69 (

0.64;

0.73)

1.39 (

1.28;

1.45)

0.94 (

0.85;

0.99)

0.45 (

0.43;

0.47)

0.48 (

0.41;

0.55)

46.73

(40.3

; 51.1

)

87.9

(68.6

; 103

.2)

99.1

(94.8

; 105

.5)

0.61 (

0.57;

0.63)

1.21 (

1.14;

1.26)

0.78 (

0.71,

0.84)

0.43 (

0.39;

0.43)

0.38 (

0.32;

0.40)

53.0

(44.2

; 58.8

)

Cond

ition

/Par

amet

ers

norm

alco

g

Veloc

ity [c

m/s]

Cade

nce [

steps

/min]

Step

tim

e [s]

Cycle

tim

e [s]

Stan

ce ti

me [

s]

Single

supp

ort t

ime [

s]

Doub

le su

ppor

t tim

e [s]

Step

leng

th [c

m]

fastc

og

Veloc

ity [c

m/s]

Cade

nce [

steps

/min]

Step

tim

e [s]

Cycle

tim

e [s]

Stan

ce ti

me [

s]

Single

supp

ort t

ime [

s]

Doub

le su

ppor

t tim

e [s]

Step

leng

th [c

m]


133

Table 5.5 Results of dual task costs of walking analysis

Condition/ParametersDance Group (n=11) Control Group (n=10)

ΔDTC % pwithin ΔDTC % pwithin pbetween r

Normal walking speed

Velocity - 8.22 0.16 + 0.90 0.96 0.29 0.23

Cadence - 4.92 0.13 + 2.85 0.80 0.15 0.32+

Step time - 5.80 0.09° + 2.00 0.88 0.25 0.27

Cycle time - 5.68 0.09° + 3.01 0.88 0.18 0.29

Stance time - 6.69 0.11 + 1.93 0.96 0.23 0.26

Single support time - 3.60 0.06° + 5.38 0.20 0.05* 0.43+

Double support time - 9.51 0.18 - 4.75 0.80 0.62 0.11

Step length - 3.54 0.21 - 2.52 0.65 0.86 0.04

Fast walking speed

Velocity - 7.07 0.04* - 3.05 0.88 0.29 0.23

Cadence - 4.35 0.09° + 0.62 0.72 0.16 0.31+

Step time - 6.27 0.08° + 5.03 0.58 0.16 0.31+

Cycle time - 6.02 0.08° + 4.74 0.58 0.16 0.31+

Stance time - 7.29 0.08° + 5.36 0.58 0.16 0.31+

Single support time - 3.51 0.21 + 4.18 0.51 0.04* 0.45+

Double support time - 13.42 0.03* + 9.23 0.33 0.18 0.29

Step length - 3.73 0.02* - 2.92 0.72 0.83 0.05

Notes: Dual task costs are illustrated as the percentage of the mean difference between pre and post intervention (ΔDTC %), negative values repre-sent a reduction of DTC, positive values represent an increase in DTC. * Significant within-group differences pre-post (pwithin ≤ 0.05) calculated with Wilcoxon signed rank test, ° Trend to significance (pwithin ≤ 0.10), * Significant between-group differences after intervention phase (pbetween ≤ 0.05) calculated with Mann-Whitney U-test, ° Trend to significance (pbetween ≤ 0.10). Abbreviations: pwithin, p-value for within-group comparison; pbetween, p-value for between-groups comparison; r, effect size (r = 0.1, small effect, +r= 0.3, medium effect).

5.4. Discussion

This randomized controlled trial was designed to test whether a twelve-week strength and

balance exercise regimen, that includes a dance video game as an additional cognitive

element, would lead to greater changes in measures of gait performance and fear of

falling, compared to strength and balance exercise alone. Although both groups attained

improvements in gait performance and were able to reduce their concerns about falling,

the results suggest positive interaction effects in favor of the dance video game group.

The finding of this study supports the notion that it is advantageous to combine physical

and cognitive training into clinical practice. The combination seems to have a positive

Chapter Five

134

Tabl

e 5.6

Resu

lts of

gaze

beha

vior a

ssessm

ent d

uring

FPA t

est

Gaze

on ta

rget

at h

eel c

onta

ct [%

] Pre

/ Po

st

C3

83 /

81

55 /

64

0 / 10

0

85 /

75

38 /

95

37 /

100

100 /

n.d.

Notes

: 1 acco

rding

to D

i Fab

io et

al 20

01 [4

8]; n

egat

ive fix

ation

value

s cor

resp

ond t

o pre

mat

ure g

aze s

hift f

rom

the t

arge

t prio

r to h

eel c

onta

ct, i.e

. tim

e fro

m ga

ze sh

ift to

heel

cont

act;

posit

ive fix

ation

va

lues c

orre

spon

d to t

he ti

me o

f per

siste

nt fix

ation

on ta

rget

afte

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l con

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the v

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‘gaz

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t’ pro

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nfor

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the l

ocat

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gaze

at he

el co

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gaze

on ta

rget

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ery

trial)

; Ab

brev

iation

s: CG

, con

trol g

roup

; DG,

danc

e gro

up; C

1-3,

Cond

ition

s 1-3

; T1-

2, Ta

rget

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no da

ta av

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le.

C2

75 /

65

70 /

73

0 / 95

100 /

85

59 /

90

0 / 73

100 /

60

C1 80 /

0

50 /

63

0 / 10

0

80 /

100

30 /

100

0 / 10

0

13 /

11

Gaze

fixa

tion

[ms]

Pre /

Pros

t

C3 - T

2

90 /

74

416 /

232

-510

/ 29

2

276 /

132

-780

/ 22

0

-98 /

400

369 /

n.d.

C2 - T

2

40 /

20

472 /

n.d.

-314

/ 24

4

320 /

188

160 /

240

-293

/ 24

8

449 /

260

C3 - T

1

132 /

140

-72 /

24

-100

5 / 18

8

148 /

52

-122

5 / 12

4

-140

/ 33

0

216 /

n.d.

C2 - T

1

180 /

87

22 /

40

-675

/ 12

4

240 /

102

6 / 14

5

-395

/ 87

84 /

-18

C1 - T

1

164 /

-171

4 / 15

3

-820

/ 15

1

228 /

380

-172

/ 21

6

-692

/ 33

6

-347

/-61

3

Clas

sifica

tion1

faller

faller

non-

faller

non-

faller

non-

faller

non-

faller

faller

Grou

p

CG CG DG DG DG DG DG

Subj

ect

1 2 3 4 5 6 7


135

influence on older adults walking abilities under dual task conditions in comparison to

more traditional exercise forms [17,18].

The most prominent differences between the training groups were observable in the

gait analysis. The CG demonstrated significant positive within-group changes of several

spatio- temporal parameters, however, merely in the single task condition and at preferred

gait speed (normal). Furthermore, this group exhibited a gain in velocity in the normalcog

condition. This merely confirms findings from a systematic review that a strength

and balance exercise regimen is able to preserve or improve walking abilities, even in

advanced age [49]. The goal of this study, however, was to improve walking behavior

under dual task conditions. The results of previous studies with similar groups, which

were performing progressive machine-driven resistance training complemented with

functional balance exercises, revealed no improvement of performance under attention-

demanding circumstances; e.g. no changes in the dual task costs of walking [50,51]. Daily

activities pose high cognitive demands and safe walking should be practicable also under

cognitive distractive or otherwise challenging conditions. The results of the DG show

significant positive within-group differences for most gait parameters also in the dual task

conditions normalcog and fastcog, thus confirming findings from previous pilot studies

with similar results for dual task related costs [27,30]. Furthermore, significant between-

group differences in the dual task condition fastcog were observed for gait velocity and

single support time in favor of the DG. Fastcog is the condition with the most challenging

motor and cognitive demands. In the present study the positive effect on DTC of gait,

represented by the decrease in ∆DTC values in the DG (Table 5.5), may be attributed to

the additional input provided by the dance video game. Thus, this substantiates the

hypothesis that an additional cognitive challenge should be preferably part of a training

program aiming to improve physical functioning in older adults, especially under dual

task conditions. Unfortunately, how gait under these conditions should be improved has

not yet been well-studied in general [52] and this study is one of the first that shows that

an improvement in dual task walking with an exercise intervention supplemented by a

video game is achievable.

Chapter Five

136

In the FPA test both groups revealed a more accurate foot placement in M-L direction

over all the walking conditions, however, only the DG manifested significant within-group

differences after the intervention. The better performance may be in part attributable to

improvements in walking and balance skills gained by the strength and balance exercises.

A higher postural balance confidence during swing phase of the gait cycle has possibly

enabled a more accurate targeting. However, a more efficient movement planning

and a possible change in visual scanning of the walking path have possibly led to the

better performance in the FPA test in favor of the DG. Interactive video games, like the

dance video game used in this study, require precise visuo-motor control, that is to focus

attention on the screen and the concurrent execution of controlled body movement and

the regulation of postural control.

Interestingly in this context is that expert action video game players were found to have

an improved spatial distribution and resolution of visual attention, a more efficient visual

attention over time and were able to attend a higher number of objects simultaneously

compared to non-players [53,54], thus allowing a better allocation of the attentional

resources over a visuo-motor task.

Interestingly, in both exercise groups the mean distance error in A-P direction

increased after the intervention. Participants were able to navigate quicker through the

test path thereby controlling their M-L direction walking deviation, however, suffered the

loss of accuracy in mean distance error in A-P direction. The higher inaccuracy in the A-P

direction may be in part explained by the higher walking velocity in the second test. It can

be suggested, that participants gave more priority to their walking performance (greater

velocity, larger steps) and their navigation towards the target in M-L direction, so that

their foot placement accuracy in A-P direction decreased (speed-accuracy tradeoff ) [55].

The quality evaluation, however, shows in general a qualitative better performance in the

second FPA test with less shoe contacts with the targets (Table 5.2).

The reason to use a dance video game or video games in general, is mainly based

on the findings of a systematic review [17]. It is, however, also related to the numerous

advantages attributed to such a tool [25]. As known from the principles of motor learning,


137

repetition is important for both motor learning and the cortical changes that initiate it

[56]. The repeated practice must be linked to incremental success at some task or goal.

A computerized intervention like the dance video game constitutes a powerful tool to

provide participant repetitive practice, feedback about performance and motivation to

endure practice [56]. In addition, it can be adapted based on the individual participant‘s

baseline motor performance and be progressively augmented in task difficulty. Further,

the addition of a challenging video game has the potential to engage people who

otherwise would lack of interest to participate in a physical exercise regimen. Especially

in the older population it is difficult to maintain high adherence to training programs

[57]. The participants of the present study showed excellent compliance rates. The losses

related to low exercise compliance or low motivation (n = 4) in the DG were caused by

animosities between the participants of one training group and in part by not perceiving

any changes in performance level at the half of the study. The reasons for discontinuation

of training were not because of rejection of the dance video game per se. The DG members

were motivated by the additional playing of the video game at the end of every training

session. The CG members were motivated by the assurance that after the end of the

intervention they had the opportunity to include the dance video game in their exercise

program as well. In both hostels, the training sessions with the additional dance video

game were pursued also after the study ended.

The high acceptance of the dance video game used in our study seems at variance with

reports of elderly being rather skeptical towards using commercially available games in

a hospital setting [58]. We think that this is partly explainable due to the modifications

made to the original dance video game free-ware StepMania. The information on the

screen was reduced to a minimum and the music was chosen according participants‘

taste. In general, commercially available video games are often not adapted to the

needs and preferences of older adults, since they are designed for children and young

adults. The games are not easy to comprehend and the screens are flashing. This might

be one of the reasons why some commercially available video games are rather disliked

by older adults [58].

Chapter Five

138

5.4.1. Limitations of the study

The present study contains some limitations that have to be discussed. A limitation of

the FPA test is that different shoe sizes of the participants are not accounted for. The

further development of the FPA test protocol should consider foot size by using different

sized foam targets. We assume that a subject with small feet has more free space in the

target area to place his/her foot before touching the border of the target resulting in a

potentially higher risk of becoming variable in the accuracy performance. On the other

hand the larger the foot the smaller the free space between foot and border of the target.

A subject with large feet will not have a comparable amount of potential variability of

distance errors as the person with small feet.

An obvious limitation of our study is the rather small sample size. This study, therefore,

only reveals first estimates for these measures and warrants further research in larger

populations. When evaluating the validity of a study it is important to consider both the

clinical and statistical significance of the findings [59]. Studies that claim clinical relevance

may lack sufficient statistical significance to make meaningful statements or, conversely,

may lack practicality despite showing a statistically significant difference in treatment

options. Researchers and clinicians should not focus on small p-values alone to decide

whether a treatment is clinically useful; it is necessary to also consider the magnitude(s)

of treatment differences and the power of the study [59]. Encouraging in this context is

the observation that the majority of the between-groups comparisons show medium or

medium-to-high magnitude(s) of treatment differences. This in mind, the relationship

between physical and cognitive training research and its effect on gait in elderly individuals

requires further exploration. Future adequately powered studies with similar populations

should, therefore, be performed to substantiate our assumption and findings.

The suggested link between the observed improvement in the physical tests after the

intervention and influences on cognitive processes in the brain is as of yet still speculative. A

necessary next step would be to investigate the isolated effects of the video game on measures

of cognitive functioning. Since improvements were observable in physical performance under

attention-demanding circumstances it seems plausible to hypothesize that these changes


139

may rely, at least in part, on functional or even structural changes in the brain. A recently

published study protocol [60] might be able to provide some insights on this topic.

5.5. Conclusions

Our results support previous larger studies that strength and balance exercise may lead to better

walking performance in older untrained subjects. Integrating a cognitive training component

in addition, results in further improvements in those walking tasks that are related to cognitive

functions. Enhancements in walking performance under dual task conditions were observed

for the dance video game group only. Our findings suggest that the addition of this particular

program to traditional strength and balance exercises may result in improved outcomes for older

people. An exercise program that aims to improve physical functioning in older adults under

dual task conditions should also consider a cognitive challenging element, preferably in form of

an interactive video game adapted for older adults, in addition to strength and balance exercises.

Acknowledgements

We would like to acknowledge Manuela Nötzli, Melanie Ramp, Rosina Landolt and Susan

Brouwer for supervising the training sessions. We would also like to thank Marie-Louise

Sarraj and Gerhard Ineichen for giving us the opportunity to conduct the study in their

hostels in Stäfa and Rüti, Switzerland. Thanks also to Rolf van de Langenberg for his

creative ideas in answering technical questions.

Authors‘ contribution

Conception, design and manuscript drafting: GP, EDdB: Critical revision of manuscript for

its content and approval of final version: GP, EDdB, KM. All authors read and approved the

final manuscript.

Competing interests


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140



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Six

Assessment of the test-retest reliability of a foot placement accuracy protocol

in assisted-living older adults

Pichierri G1, Diener T1, Murer K1, de Bruin ED1


published in Gait & Posture 38 (2013) 784–789.

Ch

ap

ter

148

Chapter Six

Abstract

Introduction: This study assessed the test-retest reliability of a foot placement accuracy

protocol in assisted-living elderly. The goal is to evaluate the execution of foot placement

performance with increasing complexity of the walking condition.

Methods: Twenty-five elderly (5 males, 20 females, 80.4 ± 8.6 years) were assessed by

one observer in two sessions with 48 hours as time interval between the measurements.

Participants walked at self-selected pace along a pathway with three different walking

conditions composed by two rectangular foam target locations and an obstacle on

the walking surface. The main outcome measures were foot placement distance error,

intraclass correlation coefficients (ICC), and the smallest detectable difference (SDD).

Results: Mean absolute values of the foot placement distance errors were 14.0 ± 4.5 mm for

medio-lateral deviation and 27.2 ± 2.1 mm for anterior-posterior deviation, respectively.

ICC values for test-retest reliability showed ‘fair to good’ to ‘excellent’ reliability across all

conditions with values ranging from 0.63 to 0.94. SDD values lie between 3.6 and 37.3 mm.

Conclusion: The protocol showed good reliability for test-retest measurements of foot

placement accuracy, thus making this protocol a reliable and location-independent tool

to assess performance of foot placement in elderly in assisted-living settings. In the future,

measurements with elderly fallers and non-fallers should be conducted to assess validity

of the protocol.

Keywords: test-retest, reliability, foot placement, elderly, video analysis

149

Assessment of the test-retest reliability

The majority of falls in the elderly occur during activities of postural transition such as

walking [1]. Controlled placement of the foot on the walking surface is essential for safe

walking, especially in challenging environments. Because increased stride- to-stride

variability [2] and decreased foot placement accuracy [3,4] are typical features of the

aging process, the elderly are at greater risk of tripping or falling.

Accurate positioning of the foot requires appropriate planning and execution of the

movement, as well as cognitive skills such as visual scanning, attention and problem solving

[5]. It has been demonstrated that elderly people that are prone to falling generally show

greater foot placement variability compared to younger adults [3]. The elderly apparently

need more time to plan accurate steps into a target due to longer eye fixation times on

the target compared to younger adults [4]. In the past there have been some attempts

to assess foot placement accuracy in elderly populations [5–8], however these have not

included quantification of the performance. Foot placement accuracy performance was

defined by whether or not the participant stepped onto a target area on the floor [5–7], or

by measuring the foot placement accuracy error in the anterior-posterior (A-P) direction

only [8].

Chapman and Hollands [3,4] in contrast, designed a protocol that enabled the

assessment of foot placement accuracy in both A-P and medio-lateral (M-L) directions.

The goal of their protocol was to evaluate the planning and execution of foot placement

with increasing complexity of the walking condition. This foot placement protocol proved

to be able to discriminate between elderly with a low-risk and a high-risk for falling.

However, the use of this protocol is dependent on dedicated gait analysis infrastructure

and, therefore, restricted to gait analysis laboratories. Further, the time required to

complete the protocol limits the use of this protocol in clinical practice [9].

Critical to the further development of therapies and interventions are easy-to-use devices

that can be applied in clinical and (care) home settings [10]. Compared to other motion

measurement devices, digital cameras have the advantage of being lightweight and

portable, thus permitting data collection in a home environment. Consequently, they

seem ideal for extending our understanding of foot placement and gait, and the causes

150

Chapter Six

of elderly gait problems in real-life conditions, and ultimately facilitate the choice or the

development of appropriate physical treatment.

To be clinically useful, an assessment procedure must have a small measurement error

to detect a real change in an individual. A test-retest difference in a patient with a value

smaller than the standard error of the measurement (SEM) is likely to be the result of mea-

surement noise and is unlikely to be detected reliably in practice; a difference greater

than the smallest detectable difference (SDD) is highly likely (with 95% confidence) to

be a real difference [11].

We conducted this study to investigate the reliability of a foot placement accuracy

protocol in an assisted-living elderly population with mobile equipment, to identify

the SEM, and the SDD. To the best of our knowledge no evaluation of reliability of the

foot placement protocol in assisted-living settings has been published so far.

6.2. Methods

6.2.1. Study design

This study was designed as a test-retest study where all subjects were tested by the

same observer. Two trials were executed on two different days with 48 h between

the measurements. The study protocol was approved by the local ethics committee.

All participants received written and oral information and were requested to sign an

informed consent statement.

6.2.2. Subjects recruitment

Letters with an explanation of the study process and its aims were sent to the residents

of two senior hostels (total: 155). 31 residents (20%) evinced interest and were

assessed for eligibility. Inclusion criteria were age over 65 years, residential status, the

ability to walk independently for at least 10 m. Exclusion criteria were severe cognitive

impairments (Mini-Mental Status Examination Score (MMSE) < 22 points), rapidly

progressive or terminal illness, acute illness or presence of an unstable chronic illness.

6.2.3. Test procedures

151


The protocol used to assess foot placement accuracy was a modification of

a previously described protocol [4,12]. Subjects were instructed to walk at self-

selected pace along a path with three different obstacle conditions (Figure 6.1 a–c):

‘Condition 1’ (C1) required subjects to place their right foot onto target 1 (T1); in

‘Condition 2’(C2) subjects were required to place their right foot onto T1 and the

left foot onto target 2 (T2); ‘Condition 3’ (C3) additionally required stepping over an

obstacle placed between the two targets. The targets and the obstacle were made

of soft foam material. The targets were rectangular (target area (TA): 190 mm × 415

mm) and comprised a raised border (40 mm × 40 mm × 40 mm). Dimensions of the

obstacle were 170 mm × 670 mm × 25 mm. 170 mm corresponds to the ideal height

of a staircase step as defined by the Federal Authorities of the Swiss Confederation.

Subjects performed ten repetitions for each walking condition, resulting in a total

of 30 trials per person. Compared to the original protocol the number of trials was

halved since we expected to have older participants with on average less optimal

physical abilities compared to the elderly in the reference studies [4,12].

Prior to the start of each trial subjects stood with their back to the walking path,

facing a wall, to limit knowledge of the pathway during adjustments of the target

position by the investigator. The target(s) appeared in two possible positions (A or B)

separated medio-laterally by 8 cm (Figure 6.1 d), an adaptation to the protocol based

on the results of Young and Hollands [12]. The presentation of the target positions

was randomized and of equal number for each condition. The presentation of the

walking conditions was not randomized.

After a verbal signal by the supervisor, subjects turned toward the pathway.

From a labeled starting position they began to walk over the path at a self-selected

pace. Subjects were verbally instructed prior to each change of walking condition to

place their foot as accurately as possible in the middle of the TA and were allowed to

perform two rehearsal walks for each condition.

152

Chapter Six

6.2.4. Data acquisition

To assess participants’ foot placement performance on the targets, adhesive labels

were placed on both shoes at calcaneus level for A-P estimation and on the level of

the head of the fifth metatarsal for M-L estimation (Figure 6.1 e). During each trial, the

targets were recorded by two stationary video cameras (Contour HD 1080p, chosen for

shooting sharp, high resolution 1080p HD video) at a sampling rate of 30 Hz. Video data was

analyzed with Vicon Motus (Version 9.2) with an accuracy of 4.30 mm (A-P)/ 1.12 mm (M-L),

and a precision of 3.39 mm (A-P)/0.87 mm (M-L), respectively. Short video sequences (4

to 5 frames) of the heel strike moment onto the target were imported into the software

(Figure 6.1 e).

First, the spatial coordinates of the TA were determined for spatial calibration. Following

this, four reference points (P0–P3) were selected, where P0 represents the point of origin. P1

and P3 represent the extension of the medial and frontal boarder of the target, respectively.

Second, the M-L and A-P distance of the foot markers to the previously defined

coordinates of the TA were calculated by the software. Finally, for the assessment of foot

placement performance, the M-L and A-P deviation of the foot center to the center of the

foam target was determined. For this purpose, the contour of the participants’ shoe sole

were traced on a sheet of paper, thus allowing identification of the foot center, which was

defined as the midpoint between heel and toe for A-P error and the midpoint between the

lateral marker and the proximal shoe border for M-L error. The foam targets were marked

with two black triangles (Figure 6.1 e), serving as calibration points to read in the dimensions

and to determine spatial orientation of the target by the video analysis software. The shape

of a triangle was chosen to facilitate identification and marking of the calibration points on

the video file.

6.2.5. Statistical analysis

The mean M-L and A-P absolute distance errors of the foot center to the target center

were calculated for each target under each condition. Normality of the data was analyzed

with the one sample Kolmogorov-Smirnov test.

153


Figure 6.1. Set-up of the foot placement accuracy protocol. Subjects were required to walk along the pathway at self-selected pace and place the right foot into target 1 (Condition 1 (a)), place the right foot into target 1 and the left foot into target 2 (Condition 2 (b)), and additionally step over an obstacle lying between the two targets (Condition 3 (c)). The target(s) appeared in two possible positions (A or B) separated medio-laterally by 8 cm to prevent task familiarization (d). Video still of camera 2 during stance phase used to evaluate the lateral (la) and posterior (po) distance error (e).

116 cm

184 cm

260 cm

a

b

c

target 1

target 2

foot marker

camera 1

camera 2

d e

target 2target 1

midli

ne

10cm2cm0x

y

po = posterior distance

pola

la = lateral distance

xy= calibration points P0

P1

P2

P3

A B

A B

154

Chapter Six

Heteroscedasticity of the data was assessed by calculating the square value of Pearson’s

correlation coefficient (r2) between the absolute measurement differences (measurement

1 – measurement 2) and the respective means. Values of r2 above 0.1 indicate

heteroscedasticity. Negative values or values below 0.1 indicate homoscedasticity.

Bland-Altman plots were created for the visual inspection of heteroscedasticity

[13,14]. If heteroscedasticity was present, data was transformed to the logarithms of

base 10 for the calculation of the reliability parameters [15]. For the relative measures of

test-retest reliability the two-way random intraclass correlation coefficients (ICC2,k) with

absolute agreement were calculated. 95% confidence intervals (95% CI) for each target

and condition were determined. The interpretation of the ICC2,k values was based on the

benchmarks suggested by Shrout and Fleiss (>0.75 excellent reliability, 0.4–0.75 fair to

good reliability, <0.4 poor reliability) [16].

To examine if a significant systematic bias existed between the test and retest and

as needed for the subsequent calculation of the absolute indices of reliability a two-

way analysis of variance (ANOVA) was performed [17]. SEM was estimated with: SEM

= SD√1 – ICC2,k) where SD is the standard deviation of the scores from all subjects

(determined from the ANOVA: √SStotal /(n – 1)) and ICC2,k is the reliability coefficient.

SStotal is the total sum of squares derived from the ANOVA. SDD was calculated with

the formula SDD = SEM x 1.96 x √2 [18]. All statistical analyses were performed with SPSS

Statistics 19. Significance level was set at α = 0.05 (2-tailed).

6.3. Results

25 subjects were recruited and signed informed consent statements. The participants’

characteristics are summarized in Table 6.1. 25 subjects, with a mean age of 80.4 years

(range 66 to 94 years), completed both measurements. From the thirty subjects who

evinced interest to participate, four were excluded for not meeting the inclusion criteria

(walking device (n = 2), MMSE score < 22 (n = 1) or too frail (n = 1)) and one person declined

to participate after the first measurement.

Data sets for A-P distance error for T1 in C1, M-L distance error for T1 in C3, and A-P

155


distance error for T2 in C2 were heteroscedastic and were log-transformed to base 10 for

calculation of the reliability parameters.

Mean absolute values and ranges of both measurements, their mean difference

with corresponding limits of agreement and 95% CI, and the results of the ANOVA are

reported in Table 6.2. Data for A-P distance error for T1 in C3 (p = 0.04) and for M-L distance

errors for T2 in C2 (p = 0.05) revealed significant differences between the measurements.

Mean absolute values of the foot placement distance errors combining all experimental

conditions and both measurements were 14.0 ± 4.5 mm for M-L deviation and 27.2 ± 2.1

mm for A-P deviation, respectively.

The results of the reliability measures and agreement parameters are shown in

Table 6.3. ICC2,k values show ‘fair to good’ to ‘excellent’ reliability results across all

conditions with values ranging from ICC2,k 0.63 to 0.94. SDD values lie between 3.6

and 37.3 mm. In proportion to the size of the TA, the SDD values range from 1.9% (3.6

mm) to 7.0% (13.3 mm) for M-L distance error, and from 0.87% (3.6 mm) to 9.0% (37.3

mm) for A-P distance error. The Bland-Altman plots are presented in Figure 6.2.

Table 6.1 Demographic data of participantsNo. of participants 25

Age (mean, range) 80.4, 66–94

Sex (female/male) 20/5

Height (m) (mean, range) 1.61, 1.37–1.78

Weight (kg) (mean, range) 67.0, 47.1–92.7

Mini-Mental statusa (median, range) 28, 24–30

FES-Ib (median, range) 17, 16–24

Walking assistance (cane) n (%) 3 (12%)

Fallsc in the last 6 months n (%)

One 7 (28%)

More than one 2 (8%)

Previous falls requiring medical attention 1

Hypertension n (%) 13 (52%)

Arthropathy n (%) 8 (32%)

Osteoporosis n (%) 4 (16%)

Diabetes n (%) 4 (16%)

Cardiac insufficiency n (%) 3 (12%)a Minimum score = 0, maximum score = 30; higher scores indicate better cognitive functioning.b FES-I: falls efficacy scale-international; minimum score = 16, maximum score = 64; lower scores indicate less fear of falling.c A fall was defined as an event, which results in a person coming to rest on the ground or other lower level.

156

Chapter Six

Tabl

e 6. 2

Dist

ance

erro

rs (fo

ot ce

nter

to ta

rget

cent

er),

mea

n diff

eren

ce d,

and A

NOVA

value

s (sa

mple

size

n =

25)

ANOV

A

p 0.53

0.26

0.49

0.89

0.05

*

0.71

0.71

0.04

*

0.69

0.92

Abbr

eviat

ions:

Cond

ition

1: on

e tar

get;

Cond

ition

2: tw

o tar

gets;

Cond

ition

3: tw

o tar

gets

plus o

bsta

cle; T

1, T2

: tar

get 1

or 2;

M-L

, A-P

: med

io-lat

eral

or an

terio

r–po

sterio

r dist

ance

erro

r of c

ente

r foo

t to

targ

et ce

nter

; d: d

iffer

ence

betw

een

the v

alue o

f mea

sure

men

t one

minu

s mea

sure

men

t two

; LoA

: lowe

r and

uppe

r lim

it of

agre

emen

t (d

± 1.

96 st

and d

eviat

ion of

d); 9

5% CI

: 95%

conf

idenc

e int

erva

l (lo

wer l

imit,

uppe

r lim

it).

F

0.401

1.333

0.494

0.019

4.272

0.139

0.145

4.583

0.162

0.010

Diffe

renc

e d 95%

CI of

d (m

m)

-3.2,

1.7

-0.5,

8.2

-3.5,

1.7

-3.3,

3.8

0.0, 4

.9

-1.8,

4.9

-2.5,

2.5

0.2, 9

.9

-1.4,

1.8

-7.1,

6.4

Mea

n (Lo

A) (m

m)

-0.7

(-12.2

, 10.7

)

3.8 (-

16.9,

24.6)

-0.9

(-13.3

, 11.6

)

0.2 (-

16.6,

17.1)

2.4 (-

9.1, 1

4.0)

1.5 (-

14.4,

17.5)

0.0 (-

11.9,

11.9)

5.0 (-

18.0,

28.0)

0.3 (-

7.0, 7

.6)

-0.3

(-32.4

, 31.8

)

Mea

sure

men

t 2

Mea

n (ra

nge)

(mm

)

13.5

(5.2,

27.3)

23.5

(9.0,

45.9)

14.1

(5.1,

41.5)

27.5

(1.2,

52.7)

14.0

(4.5,

51.3)

23.8

(8.4,

57.2)

14.3

(6.6,

49.3)

30.4

(8.2,

60.7)

13.6

(5.1,

42.2)

25.7

(0.8,

86.8)

Mea

sure

men

t 1

Mea

n (ra

nge)

(mm

)

12.8

(7.3,

30.6)

27.3

(7.6,

57.3)

13.2

(4.4,

41.2)

27.7

(8.2,

54.6)

16.4

(6.1,

44.7)

25.4

(9.7,

66.5)

14.3

(7.2,

33.1)

35.4

(0.3,

68.2)

13.9

(5.2,

36.0)

25.4

(2.1,

65.3)

Dire

ctio

n

M-L A-P

M-L A-P

M-L A-P

M-L A-P

M-L A-P

Targ

et

T1 T1 T1 T1 T2 T2 T1 T1 T2 T2

Cond

ition

1 1 2 2 2 2 3 3 3 3

157


0.5

1.0

1.5

2.0

2.5

3.0

-2.0

-1.00.0

1.0

2.0

Cond

ition

1, t

arge

t 1 (M

-L)

Mea

n la

tera

l dist

ance

[cm

]

Mean difference of lateral distance [cm]

+1.9

6 SD

-1.9

6 SD

mea

n

1.0

2.0

3.0

4.0

5.0

-2.0

-1.00.0

1.0

2.0

3.0

4.0

Mean difference of posterior distance [cm]

Cond

ition

1, t

arge

t 1 (A

-P)

Mea

n po

ster

ior d

istan

ce [

cm]

0.0

1.0

2.0

3.0

4.0

5.0

-2.0

-1.00.01.0

2.0


Mea

n la

tera

l dist

ance

[cm

]

Cond

ition

2, t

arge

t 1 (M

-L)

Mea

n po

ster

ior d

istan

ce [

cm]


1.0

2.0

3.0

4.0

5.0

6.0

-2.0

-1.00.0

1.0

2.0

Cond

ition

2, t

arge

t 1 (A

-P)

Mea

n la

tera

l dist

ance

[cm

]

Mean difference of lateral distance [cm]Co

nditi

on 3

, tar

get 1

(M-L

)

1.0

2.0

3.0

4.0

-2.0

-1.00.0

1.0

2.0

1.0

2.0

3.0

4.0

5.0

6.0

Mea

n po

ster

ior d

istan

ce [

cm]


Cond

ition

3, t

arge

t 1 (A

-P)

1.0

2.0

-1.0

-2.0

Figu

re 6

. 2 B

land-

Altm

an p

lots w

ith th

e mea

n lat

eral

/ pos

terio

r dist

ance

[cm

] plot

ted

again

st th

e cor

resp

ondin

g m

ean

differ

ence

bet

ween

mea

sure

men

t 1 an

d m

easu

rem

ent 2

[cm

]. M

ean

differ

ence

(d

otte

d line

s) an

d upp

er an

d low

er lim

its of

agre

emen

t (da

shed

lines

) are

show

n.

158

Chapter Six

Mea

n la

tera

l dis

tanc

e [c

m]

0.0

1.0

2.0

3.0

4.0

5.0

-1.5

-0.50.5

1.5

Mean difference of lateral distance [cm]C

ondi

tion

2, ta

rget

2 (M

-L)

Mea

n po

ster

ior d

ista

nce

[cm

]1.

02.

03.

04.

05.

06.

07.

0

Mean difference of posterior distance [cm] -2.5

-1.5

-0.50.5

1.5

2.5

Con

ditio

n 2,

targ

et 2

(A-P

)

Mea

n la

tera

l dis

tanc

e [c

m]


0.0

1.0

2.0

3.0

4.0

-1.0

-0.5

0.0

0.5

1.0

Con

ditio

n 3,

targ

et 2

(M-L

)

Mea

n po

ster

ior d

ista

nce

[cm

]


1.0

2.0

3.0

4.0

5.0

6.0

-8.0

-6.0

-4.0

-2.0

0.0

2.0

4.0

Con

ditio

n 3,

targ

et 2

(A-P

)

Figu

re 6

. 2 (c

ontin

ued)

Blan

d-Al

tman

plot

s with

the m

ean l

ater

al / p

oste

rior d

istan

ce [c

m] p

lotte

d aga

inst t

he co

rresp

ondin

g mea

n diff

eren

ce be

twee

n mea

sure

men

t 1 an

d mea

sure

men

t 2 [c

m].

Mea

n dif

feren

ce (d

otte

d line

s) an

d upp

er an

d low

er lim

its of

agre

emen

t (da

shed

lines

) are

show

n.

159


Table 6.3 Reliability measures and agreement parameters (sample size n = 25)

Condition Target Direction

Reliabilitymeasures

Agreementparameters

ICC2,k

95% CIfor ICC2,k

SEM(mm)

SDD(mm)

1 T1 M-L 0.70 0.31, 0.87 4.7 13.0

1 T1 A-P 0.66 0.24, 0.85 1.7 4.8

2 T1 M-L 0.85 0.66, 0.93 4.8 13.3

2 T1 A-P 0.89 0.74, 0.95 6.3 17.5

2 T2 M-L 0.88 0.71, 0.95 4.7 13.0

2 T2 A-P 0.85 0.65, 0.93 1.3 3.6

3 T1 M-L 0.78 0.50, 0.90 1.3 3.6

3 T1 A-P 0.83 0.61, 0.93 9.5 26.4

3 T2 M-L 0.94 0.85, 0.97 2.7 7.4

3 T2 A-P 0.63 0.14, 0.84 13.4 37.3

Abbreviations: Condition 1: one target; Condition 2: two targets; Condition 3: two targets plus obstacle; T1 & T2: target 1 or 2; M-L & A-P: medio-lateral or anterior-posterior distance error of foot center to target center; ICC2,k: intraclass correlation coefficient (two-way random with absolute agreement); SEM: standard error of measurements in mm; SDD: smallest detectable difference in mm.

6.4. Discussion

The purpose of this study was to determine the test–retest reliability of the

modified foot placement accuracy test with mobile equipment applied with a

healthy elderly population in assisted-living settings. The results show ‘fair to

good’ to ‘excellent’ reliability parameters, thus making this protocol a reliable tool

to assess performance of foot placement in healthy elderly people in assisted-

living settings.

Our study population was representative of a typical population in senior care

homes when the demographic variables are considered. A wide age range (66–94

years), high percentage of women (80%), and MMSE scores ranging from 24 to

30 points, that is from the edge to mild cognitive impairments to no cognitive

impairments. This indicates our results can be generalized to comparable

populations of elderly people in clinical settings.

160

Chapter Six

In this study we used the ICC2,k with corresponding 95% CI to estimate relative

reliability. We observed prevalently ‘excellent’ ICC2,k values for C2 (ICC2,k = 0.85–0.89)

with narrow 95% CI values ranging from 0.65 to 0.95. In contrast C1 and C3 showed

ICC2,k values between ‘fair to good’ and ‘excellent’ (ICC2,k = 0.63–0.94) but wider ranges

of corresponding 95% CI (range from 0.14 to 0.97). Therefore it seems plausible to

assume that C2 is the more reproducible condition for elderly people.

The reason for these results could be that participants made use of C1 to acclimatize

to the test. This could be interpreted as a need for more rehearsal trials ahead of the

actual testing. C3 was more complex than C2 since participants were required to

decelerate, take a step over the obstacle and accelerate toward T2. Since the mean

age of our participants was 80.4 years it is plausible to think that C3 posed a more

challenging condition for some of the participants compared to others, explaining

the high variability of the results and the low reproducibility of the performance. It

could also be argued that some participants, especially the older ones, felt tired after

the first two conditions, which may have caused inaccuracies during walking. C2 on

the other hand, represented a more constant and rhythmical condition since it did not

require any changes in pace.

To detect relevant changes in performance of foot placement accuracy on an

individual level in clinical practice, the changes should exceed the SDD values

presented in Table 6.3. However, it is difficult to say whether the SDD values are

adequate to detect clinically meaningful differences on an individual level following

an intervention. At present the data used to categorize individuals as being at high-

risk for falls based on their foot placement accuracy, is poor and reported somewhat

contradictorily. Chapman and Hollands observed similar high values for foot placement

distance errors for both young adults and for elderly people prone to falling [3]. Their

values are in line with the values in our study over all test conditions. Interestingly,

elderly people with a low-risk for falls manifested lower values for distance errors,

which could be interpreted as a more accurate performance. In contrast, in the study

published in 2007, high-risk elderly people showed lower values for distance error

161


compared to both the low-risk and the young group [4]. This is one of the reasons why

further research should aim to acquire a broader collection of data in clinical settings.

One limitation of the protocol was that participants’ different foot sizes were not

accounted for. We assumed that a subject with smaller feet had more free space in the

TA to place his foot before touching the border, resulting in a potentially higher risk

of becoming variable in accuracy performance. On the other hand the larger the foot,

the smaller the free space between the foot and the border of the target. Therefore, a

subject with large feet may not have a comparable amount of variability in distance

errors as a person with smaller feet. A further development of the test protocol should

consider foot size by using different sized foam targets for instance. The small bias

from test to retest suggests learning effects of the protocol and can therefore be

considered as another limitation. Learning effects negatively influence reliability and

might be prevented by increasing the number of practice trials [19]. In frail elderly

people however, extensive testing might also cause systematic bias. A solution for this

problem might be the performance of several trials taken over several days in order

to control for learning effects. Furthermore, the occurrence of trial-to-trial learning

effects should be limited by a randomized presentation of the walking conditions.

6.5. Conclusion

This study showed good reliability for test–retest measurements of the foot placement

accuracy protocol, thus making this protocol a reliable and location-independent tool

to assess performance of foot placement in groups of elderly people in assisted-living

settings. However, the study should be repeated, taking into account the improvements

of the protocol as suggested in the limitations, and preferably with a sample of non-fallers

and frequent fallers to assess the ability to differentiate between these groups.

162

Chapter Six

Funding

No external funding.

Acknowledgements

Special thanks go to Gerhard Ineichen and Hans van het Reve for giving us the

opportunity to conduct this study in their hostels in Rüti and Feusisberg, Switzerland.

We also acknowledge Eva van het Reve’s and Rosina Landolt’s efforts for organizing the

measurements and for motivating the participants for this study.

Conflict of interest statement


163


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19 Atkinson G and Nevill AM. Statistical methods for assessing measurement error

(reliability) in variables relevant to sports medicine. Sports Med. 1998; 26: 217-38.

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General Discussion

Ch

ap

ter

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Physical and cognitive decline are amongst the many factors that are thought to be

responsible for the increased fall risk in the older population. In the last few years the

awareness of the link between cognitive decline and the decline of physical functioning,

i.e. the decrease of walking abilities or impaired postural control, has given rise to novel

approaches for the prevention or reduction of the occurrence of falls in older adults.

In particular, cognitive decline that affects complex cognitive structures such as the

executive functions has been made responsible for the higher fall rate in older adults. The

many observations made in dual task experiments comparing younger with older adults

has led to the suggestion that a cognitive-motor approach should preferably be part of an

effective fall prevention training program.

This doctoral thesis discusses approaches that require consideration with a view to

including a stimulating cognitive factor to fall prevention training programs. Further, this

thesis aims to investigate the current state of research into using cognitive elements in

fall prevention or interventions with the aim of improving physical functioning in older

adults. Based on these findings, two intervention trials with a randomized controlled

study design that used a cognitive-motor approach with residents of four senior hostels in

Switzerland were performed. The objective of these studies was to examine the feasibility

and acceptance of the cognitive-motor approach, and to assess the benefits to the

participants of the cognitive-motor training program of including additional computer

game dancing in progressive strength and balance exercises, compared with those who

only received usual care or performed only strength and balance exercises. In this chapter

the main findings of the literature investigation and of the experiments are summarized

and discussed. In a second step methodological issues and clinical implications are

addressed. To conclude, future perspectives and conclusions are presented.

7.1. Main findings

7.1.1. The current use of cognitive-motor techniques for rehabilitation (Chapter 2 & 3)

There is limited current evidence on the effectiveness of cognitive or cognitive-motor

approaches on physical functioning with the objective of reducing the occurrence

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General Discussion

of falls in older adults. The many pilot or case studies traced by the systematic review

(Chapter 3) clearly indicate that the use of cognitive or cognitive-motor approaches

to influence physical functioning in older adults is still in its fledgling state. Although

numerous studies have detected the dual task performance deficiency of older adults in

the past, surprisingly, there seems to be an inexistent practical use of dual task methods

in the context of intervention studies for rehabilitation purposes. The systematic review,

together with the conclusions of the theoretical discussion offered in Chapter 2, conclude

that approaches using computerized gaming techniques are the most convenient

methods to be used for the implementation of cognitive elements in a training program

with the aim of simulating a dual task condition. As early as the late 1990s, computerized

gaming techniques had begun to be developed and to be considered as a potential tool

for physical rehabilitation. Computerized gaming techniques were suggested to be able

to enhance the way older adults perceive their bodies within their environment, due to

the concordance of visual and proprioceptive information during training [1].

Computer games offer almost unlimited possibilities to implement into a training

program challenges that are close to reality. They provide scenarios that stimulate and

induce naturalistic movement and behaviors in a safe manner and they can be easily

shaped and adapted to the individual needs of the target subjects. Further, they provide

sufficient gaming experience to distract the subject’s attention from motor insecurities or

pain. To date the majority of the computer games for motor rehabilitation purposes are

found in the treatment and care of stroke patients, people with acquired brain injury, and

Parkinson’s disease sufferers [2, 3]. The aim of these studies in general is to rehabilitate

movements of upper and lower extremities that are important for activities of daily

life. With the help of computerized interventions the therapy sessions are motivating,

improvements in performance can be easily recorded and the level of difficulty can be

adjusted individually. The main finding of the systematic review is that to date there is

an insufficient application of cognitive or cognitive-motor interventions with the aim

of improving physical functioning. Further, computerized interventions for older adults

have to date seldom been applied or reported. Thus, the performance of experiments

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and interventions using a cognitive or a cognitive-motor approach that uses interactive

computerized technologies is a justifiable and desirable objective.

7.1.2. The effects of a cognitive-motor intervention on voluntary step execution in

older adults (Chapter 4)

The execution of a timed voluntary stepping response is essential for tasks that demand

avoidance of a threat or recovery of balance during walking or whilst performing postural

transitions. It has been observed that individuals who require more time to initiate and

execute a step are at greater risk of falling [4–6]. In older adults the ability to execute a

quick step response further decreases in attention-demanding situations [7, 8].

The randomized controlled pilot study presented in Chapter 4 focused on the

evaluation of the effects of a twice-weekly exercise program enhanced by supplemental

computer game dancing for 12 weeks (n = 9) in comparison to usual care (n = 6) in older

adult residents of two senior hostels in the city of Zurich. Furthermore, the study examined

the feasibility and the potential to recruit and retain elderly subjects.

For the first time this intervention study revealed temporal improvements in voluntary

step execution under dual task conditions in older adults. The between-group comparison

resulted in a significant decrease of step initiation time (U = 9, p = 0.034, r = 0.55)

and step completion time (U = 10, p = 0.045, r = 0.52) in favor of the cognitive-

motor group. Additionally, the study participants showed an excellent mean compliance

rate of approximately 87%, thus substantiating the suggestion that a cognitive-motor

intervention that includes progressive strength and balance exercises supplemented by

an interactive dance video game is feasible and appreciated by older adults.

7.1.3. The effects of a cognitive-motor intervention on foot placement accuracy and

gait under dual task conditions and falls efficacy in older adults (Chapter 5)

Intact walking abilities are certainly one of the most important factors for the preservation

of autonomy and independence in everyday life. The accurate positioning of the foot onto

a footpath, for instance, is a crucial ability to ensure safe walking. It enables the avoidance of

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General Discussion

missteps and the handling of potential threats to postural stability. Furthermore, reduced

gait abilities under attention-demanding conditions, and the slowing of usual gait velocity

are associated with a higher risk of falls and with a decline in attention and psychomotor

speed [9, 10]. It has even been suggested that improvements in usual gait velocity predict

a substantial reduction in mortality [11]. Both the decreased foot placement accuracy and

the general reduced walking abilities are often reported as common symptoms of the

natural aging process. In this regard, fear of falling is a frequently reported concern in

older adults, especially in individuals who have already experienced a fall, and can lead to

a further decrease in activity of daily life, a further decline in physical functioning and to a

general decrease in quality of life [12, 13].

Chapter 5 highlights the effects of a 12-week randomized controlled intervention

study of residents of two senior hostels regarding foot placement accuracy and gait under

dual task conditions, coupled with fear of falling. The participants either performed a

cognitive-motor program that comprised twice-weekly progressive strength and balance

exercises with supplemental computer game dancing (n = 15) or progressive strength

and balance exercises alone (n = 16). Although both groups attained improvements in

foot placement and gait performance and both were able to reduce their concerns about

falling, the results of this study suggest positive interaction effects in favor of the cognitive-

motor group. The cognitive-motor group achieved significant positive within-group

differences for most gait parameters assessed under both single and dual task conditions.

Furthermore, significant between-group differences for gait velocity (U = 26, p = 0.041,

r = 0.45) and single support time (U = 24, p = 0.029, r = 0.48) under dual task conditions

in favor of the cognitive-motor group were observed. However no significant between-

group differences were found for foot placement accuracy after the intervention − only

the cognitive-motor group exhibited significant positive within-group differences after

12 weeks. The results suggest that a cognitive-motor intervention may have a positive

influence on dual task walking abilities in older adults compared to a traditional exercises

regimen. The addition of a cognitive training component results in further improvements

in those walking tasks that are related to cognitive functions.

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7.1.4. The test-retest reliability of the foot placement accuracy test (Chapter 6)

Knowledge of data reliability allows the use of a system in observational and interventional

type studies. The study presented in Chapter 6 assessed the test-retest reliability of a foot

placement accuracy protocol performed with mobile equipment in assisted-living elderly.

One observer assessed twenty-five elderly residents of two senior hostels in two sessions

with a 48-hour time interval between measurements. Participants walked at a self-

selected pace along a pathway with three different walking conditions composed of two

rectangular foam target locations and an obstacle on the walking surface. The analysis of

the foot placement performance was performed by the help of commercially available

digital video cameras and software able to identify the spatial position of objects and to

calculate relative distances to other objects based on video data. The results show ‘fair to

good’ to ‘excellent’ reliability parameters and SDD values in a small range, thus making

the foot placement accuracy test protocol a reliable tool to assess performance of foot

placement in healthy elderly in assisted-living settings.

However, it is difficult to say whether the SDD values are adequate to detect clinically

meaningful differences on an individual level following an intervention. Therefore, further

research should aim to acquire a broader collection of data, especially with groups of non-

fallers and frequent fallers, in clinical settings.

7.2. Methodological issues

7.2.1. Systematic review (Chapter 3)

Although the primary objective of the review was to identify intervention studies

using cognitive or cognitive-motor interventions affecting physical functioning in an

older population, studies including people with neurological deficits were considered

as a methodological supplement with the intention of receiving useful inputs for the

application in studies with older adults. People with neurological deficits as a cause of

brain dysfunctions behave very similarly to older adults, although the causes of the deficits

are different. Whether brain functions are lost through a sudden accident or through slow

and gradual decline, as it is in older adults, both result in more or less the same behavioral

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General Discussion

symptoms and deficits, that is slowing of gait together with variability of temporal

and spatial gait parameters under single and dual task situations. The consideration of

other groups for the systematic literature search turned out to be fundamental for the

methodological content and the completeness of the review, since a majority of the

studies were conducted with older adults not in full health.

8.2.2. Randomized controlled pilot study (Chapter 4)

The small sample size definitely hinders the generalization of the results reported for the

pilot study presented in Chapter 4. Presumably, a larger sample size in both the cognitive-

motor and usual care group would have led to different results. The rationale for the

performance of this pilot study was purely scientific. Besides estimating possible effects

on physical functioning and the feasibility of a cognitive-motor approach the study was

concerned with the assessment of treatment safety, the determination of dose levels and

response. As Thabane, L. et al., stated [14]: “Pilot studies can be very informative, not only

to the researchers conducting them but also to others doing similar work. However, many

of them never get published, often because of the way the results are presented. Quite

often the emphasis is wrongly placed on statistical significance, not on feasibility – which

is the main focus of the pilot study.”

Certainly, an effective replication of the study should not only consider a larger number

of participants but also additional clinical meaningful measures of physical performance

such as the Expanded Timed Get-Up-and-Go test (ETGUG) [15], the Berg Balance Scale

[16], or the Activities-specific Balance Confidence Scale (ABC) [17]. These assessments may

contribute to a better and more comprehensible estimation of the effects observed on

the voluntary step execution task.

The comparison of the cognitive-motor group with a control group that received

only usual care is not recommendable by implication. It remains unclear whether

the positive results were a consequence of the additional dance computer game

alone, or of the cognitive-motor intervention as a whole. Therefore, the randomized

controlled study presented in Chapter 5 focused on separating the contribution of

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the isolated training parameters, i.e. progressive strength and balance exercise and

interactive computer game dancing.

Nevertheless, the comparison reveals obvious deficiencies in the usual care

management in senior hostels. The two hostels considered for this pilot study lacked a

systematic physical exercise program as well as appropriate infrastructures to perform

physical activity for the resident older adults. This is a common problem in Swiss residential

settings [18].

7.2.3. Randomized controlled study (Chapter 5)

From the viewpoint of the assessments performed in the context of the study presented

in Chapter 5, some methodological issues need to be discussed. One major limitation

of the study is the absence of complete gaze behavior data during the foot placement

accuracy test. This substantial data deficiency makes it impossible to draw a relationship

between the improvements in the foot placement accuracy task and a possibly changed

gaze behavior as suggested by the reference studies [19–21]. Not only were technical

problems experienced, but also several age-related difficulties (vision problems) that

hampered the use of the eye-tracking system, thus bringing up the question whether

such an eye-tracking system is suitable for adults in this age category. In a future study

subjects who are not able to walk without glasses, subjects suffering from head tremor, or

those who have hanging eyelids should be excluded from the measurements.

Furthermore, some modifications in the foot placement accuracy test are necessary.

Participants were told to face a wall prior to the start of the test to prevent pre-walking

adjustments when aware of the targets’ medio-lateral position. After the visual start signal

appeared they performed a body turn of 180° towards the walking path. This body turn

could have been the origin of unwanted vestibular effects and may have influenced

the performance of the foot placement accuracy test. Nonetheless, as the time needed

to perform the body turn and perform the first step was not limited, the occurrence of

unwanted vestibular effects and its influence on performance can be disregarded. In

contrast, the participants in the reference studies [19–21] were told to close their eyes to

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General Discussion

prevent catching a premature view of the walking path. Closing and opening the eyes may

also have an influence on the vestibular system, since participants begin to walk during

the light adaptation phase of the eye. A possible method of avoiding both unwanted pre-

start effects is the use of an easily removable wall on wheels between the participant and

the walking path.

From the viewpoint of the exercise program there is no need to change the design of

the cognitive-motor intervention used in this study. Participants very much enjoyed the

physical exercise as well as playing the dance video game. Some participants involved

in the performance of the dance video game suggested that the music could have been

more diversified, but this was reported as a minor issue. However, suggestions of this kind

should be taken seriously, since they may influence adherence to the training program

and the results of the study.

As in the pilot study offered in Chapter 4 the randomized controlled trial presented

in Chapter 5 showed small sample sizes although numerous residents attended the

recruitment events. For future studies the participant recruitment process should

be more focused on establishing a personal relationship between the investigators

and the residents of the senior hostels, right from the start. The support of the hostel

staff is therefore crucial, as they know the residents and are able to convince potential

participants in case of concerns about the participation to the study. The presentation of

videos and pictures of previous studies showing participants during the performance of

the training program is definitely helpful to provide confidence and assure that the study

is safe and especially designed for the older population. Having been more conscious of

these aspects possibly would have resulted in a larger study population.

7.2.4. The test-retest reliability study (Chapter 6)

The study that examined the test-retest reliability of the foot placement accuracy test

(Chapter 6) did not account for test to retest learning effects. To control for these learning

effects, the performance of several trials taken over several days is recommended. Further,

the trial-to-trial learning effects should be limited by a randomized presentation of the

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walking conditions. As a matter of convenience the walking conditions were presented in

order of their complexity, i.e. one target, two targets, two targets with the obstacle.

7.2.5. Falls ascertainment

The fact that we did not ascertain falls after the intervention periods of both studies is a

point that needs to be discussed. Participants should be followed up for a certain period,

preferably 12 months, in order to assess the incidence of falls. In both intervention studies

only a retrospective data assemblage of falls data was performed. Participants were asked

how many times they had fallen in the last year or the last six months. Such an approach

is misleading because of failings in a participant’s memory of fall events over such a long

period of time. For future studies a prospective report of falls experiences should be

considered. This can be done by a self-reported bi-weekly or monthly falls diary, where

the participants report a fall event, its cause, and can note the environmental conditions

in which the fall happened. The accuracy of the fall reports increases when staff in senior

hostels are involved in the collection of falls data. Information on prospective falls data is

important to evaluate the long-term effects of an intervention.

7.3. Using computer games for older adults

The dance video game setting used in the context of this thesis is one possible approach to

using computerized methods. The advantage of using dance pads is that stepping on the

pad requires repetitive, well-coordinated leg movements and the regulation of postural

balance during the course of the training. The motivating component ‘music’ and the

performance of a step choreography on the dance pad in synchronization with music is

a complex sensorimotor action. Further, the continuous feedback on performance of the

dance computer game is very important for the participants since older adults may show

age-related deficits in self-monitoring [22, 23]. The feedback encourages the participants

to persevere with the game.

The most important aspect when using computer games for older adults is the

consideration of their preferences and needs for an aged-based adaptation of these games

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General Discussion

[24]. This was shown by a recent study from Australia that investigated the acceptability of

a commercially available interactive video games as a therapeutic tool in health and aged

care settings [25]. The conclusion was that the usefulness of a commercially interactive

mainstream video game, in their case the Nintendo Wii Fit, is limited. Although the

Nintendo Wii Fit has become a popular tool in rehabilitation settings the applicability to

the older population is not warranted. Contemporary mainstream computer games are

designed for children or younger adults, they do not cope with the needs, interests and

abilities of older adults. The animation on the screen is colorful, blinking and overloaded

with information.

Computer games for older adults with the aim of improving physical functioning under

dual task conditions should focus on the stimulation of executive functions, especially on

divided attention and should preferably implement strength and balance exercises.

7.4. Clinical implications

Cognitive impairment should be regarded as one important point of future fall

prevention programs. Actual guidelines that prescribe adequate fall risk assessments

still do not propose the assessment of cognitive impairments for fall prevention. The

guidelines for the prevention of falls published by the American Geriatrics Society,

the British Geriatrics Society, and the American Academy of Orthopedic Surgeons

Panel on Falls Prevention propose the assessment of fall history, medication,

vision, gait and balance, lower limb joints, neurological (sensory neuron and

motor responses) and cardiovascular factors [26]. Although these assessments

cover a diversified list of potential fall risk factors, cognitive impairments such as

impaired executive functions, dementia, cognitive dysfunctions following traumatic

brain injuries or stroke are not considered. A complete fall risk assessment should

consider the cognitive domain. Cognitive tests for executive functions and the

assessment of physical performance, e.g. gait under dual task conditions, should be

considered in routine assessments for older adults. Many other researchers support

this suggestion [11, 27–29].

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Progressive physical activity that comprises strength exercises focusing on muscle

groups that are used in everyday situations and the improvement of postural balance

enriched with a cognitive element should be part of any training program for older adults.

Thereby the aspect of group exercise is very important, especially in institutionalized

older adults where people tend to live their own lives regardless of the cohabitants. An

exercise program should be considered as a regular social event where people meet and

enjoy the common activity. The addition of a computer game such as the dance video

game used in the experiments in the context of this doctoral thesis integrates not only

physical activity and cognitive challenges but also offers emotional inputs to support

social cohesion between the inhabitants of a senior hostel.

When planning intervention studies for improving physical functioning in older adults

one should not be too cautious or blinded by too many prejudices. The perception that

computer games in general cannot be adapted to older adults' abilities and needs is fatal,

since aged people can be young at heart. Introducing a gaming effect and a healthy

portion of competition is important also in the old age. This could possibly be an argument

for higher participation rates in future studies. Low participation rates are a big problem in

exercise studies with older adults.

Further, the adequate design of computerized gaming techniques that focus on

improving physical functioning in older adults should be easily and economically

incorporated into home-based training programs without the need of any expensive and

unfamiliar settings.

7.5. Suggestions for future research

In a next step the effective contribution of the computer dance game on the

observed improvements in physical performance under dual task conditions

should be evaluated. The study would thus compare one group that performs

physical exercise alone, one group that performs the cognitive-motor program,

and a third group that performs only the computer dance game during the whole

study period of twelve weeks. Main outcome measures would be the assessment

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General Discussion

of gait and of other relevant fall-related physical performances under dual task

conditions.

A model where cognitive stimuli are suggested to have an impact on physical

functioning could be examined. The question would be whether improvements in

gait under dual task conditions can be observed when the dance computer game is

played with a hand-held controller

(HC) only (Figure 7.1) instead of

whole-body step training (WBT) on

the original dance pad. The HC- and

WBT-group would exercise twice

weekly or more for 12 weeks. Main

outcome measures would be pre-

and post-tests of gait performance

or of other relevant fall-related

physical performances under dual task conditions. The hypothesis is that the WBT-

group will show better performances in dual task walking compared to the HC-group.

This would speak in favor of the suggestion that the cognitive and the motor element

have to be performed together. In case of improvements in dual task performance

of the HC-group after the purely cognitive training, such a design could possibly be

applied in the workout of rather frail older adults, who are not yet able to take part in

a WBT-training.

In fact, the dance computer game implies that participants are standing on the

dance pad for several minutes. Even with the help of the hanging ropes, this is an

ability that cannot be taken for granted for a great part of institutionalized older

adults. Unfortunately, some individuals interested in participating had to be excluded

from the training program, including those who required the use of a wheelchair, or

suffered from muscle weakness that restricted the ability to stand for such a long time,

or who just felt too insecure while standing without device support. An adaptation of

the training program specifically for this group of older adults that are overlooked

Figure 7. 1 Hand-held controller ( 20 x 20 x 60 cm)

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Chapter Seven

in the majority of training studies should be designed. Strength and balance

exercises that can be performed in a seated position should be implemented. The

dance computer game could be performed by stepping on the dance pad in a sitting

position or by performing the game with the hands using an appropriately designed

hand controller constituting a miniature dance pad (Figure 7.1). This approach would

constitute a valuable opportunity for weaker and physically impaired older adults to

start with physical exercise in a safe manner. As main outcome measures in these

groups simple or choice reaction time of upper and lower extremities under dual task

conditions are suggested.

The next step should be the investigation of the dance computer game on a

neuropsychological level. It is still unclear what the underlying factors are that lead

to the improvements in physical functioning under dual task conditions in older

adults. We can only speculate that the dance computer game has an influence on

executive functions. However, first pilot findings suggest that interactive computer

dance gaming is associated with increased fronto-parietal network activation [30].

The further investigation of the dance computer game should focus on whether and

how the game stimulates and affects brain activity, with a focus on prefrontal brains

structures. Measurement of brain activity with electroencephalogy (EEG) during the

performance of the computer task or functional magnetic resonance imaging (fMRI)

before and after the cognitive-motor intervention could reveal which and to what

extent specific brain functions are active or affected during and after the performance

of the dance computer game. An interesting point would be to explore whether

the possibly observed changes in brain activity are achieved by structural and/or

functional changes in the brain. Three groups would be tested after a training regimen

of either computer game dancing, computer game dancing with a hand-held controller

(Figure 7.1), traditional stepping exercises and compared to a non-intervention group.

In addition, with the integration of the possibly new insights regarding the effect

of an interactive dance video game on brain level, new types of interactive computer

games especially designed and adapted for older adults should be developed.

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General Discussion

7.6. Conclusions

This doctoral thesis highlights the fact that the use of cognitive-motor approaches

is still in its fledgling state, thus justifying the need for further research in the use

of cognitive-motor approaches for the improvement of physical functioning and

fall prevention in older adults. The suggested link between cognitive functions and

physical functioning should be taken into account in future studies aiming to improve

the ability of older adults to counteract threats to their postural stability. Furthermore,

cognitive impairments and decreased dual task performances in older adults should

be considered in routine assessments to identify at an early stage dysfunctions in this

context. The findings arising from the interventions performed in the experimental

context of this thesis substantiate the hypothesis that physical exercise enriched by

supplemental cognitive stimuli, in the form an interactive and attention-demanding

computer game, has an essential positive benefit on the physical performance

of older adults under attention-demanding circumstances when compared to

previously applied physical exercise regimen. However, it remains unclear to what

extent the additional cognitive input is responsible for the observed improvements

of performance.

To conclude, the design of future training approaches and interventional studies

should consider the needs, interests and abilities of the older population to ensure

adherence and persistence.

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29. Muir SW, Gopaul K, Montero Odasso MM: The role of cognitive impairment in

fall risk among older adults: a systematic review and meta-analysis. Age Ageing

2012, 41(3):299-308.

30. Jovancevic J, Rosano C, Perera S, Erickson KI, Studenski S: A protocol for a

randomized clinical trial of interactive video dance: potential for effects on

cognitive function. BMC Geriatr 2012, 12:23.

185

General Discussion

Eight

Summary / Zusammenfassung Danksagungen

PhD CurriculumCurriculum Vitae

Ch

ap

ter

Summary / Zusammenfassung

190

Chapter Eight

Summary

Our body is constantly challenged not only by different internal influences (muscle

weakness, illness, fatigue, mood, cognitive impairments, vision problems) but also by

external ones (obstacles, crowds, traffic, weather) all of which constitute a potential threat

to our postural stability. These demand intact cognitive functions to register potentially

threatening situations at an early stage, to plan and execute the correct motor response to

the special circumstance in order to avoid a misstep or a fall. Besides the decline of physical

functions, a decline of cognitive functions that regulate these abilities has been suggested

as a major cause for falls in the older population. It has been extensively observed that older

adults show poorer performances in dual task situations compared to younger adults, and

this deficiency is thought to be in part attributable to declines in executive functioning.

The thesis aims to answer the question of whether effective fall prevention programs

for older adults should implement approaches that address the cognitive decline and the

dysfunctions in cognitive processes, especially of the executive functions. The assumption

is based on the growing evidence that rather than isolated physical or cognitive activity, the

combination of both better supports the healthy functions of executive function, working

memory, and the ability to divide and select attention. The results of a systematic review

of literature (Chapter 3) reveal that the current evidence on the effectiveness of such

approaches on physical functioning under single and dual task conditions in older adults is

still limited, thus warranting the performance of experiments and interventions using such

a cognitive-motor approach for this population.

The thesis proposes the use of interactive computer games as a supplement to traditional

physical exercise procedures, that is strength and/or balance exercise. The special value of

interactive computer game training paradigms is believed to be due to the concordance

of visual and proprioceptive information during training. Further, interactive computer

games provide salient feedback about the movement performance and the task difficulty

can be easily adapted according to the subject’s ability and needs. The computer game

used in the experiments is an interactive dance game (a specially designed modification

of StepMania, Version 3.9) based on the performance of precise and timed steps on a metal

191


pad in response to visual and acoustic stimuli. Subjects are expected to observe the virtual

environment on a screen indicating moving arrows and concurrently initiate appropriate

dance steps (forwards, backwards and to the side, respectively). The dance game challenges

body coordination and attention at the same time.

In two intervention studies (Chapter 4 and 5) older adults in care home settings in

Switzerland performed for twelve weeks either a cognitive-motor program that comprised

twice-weekly progressive strength and balance exercises with supplemental interactive

computer game dancing (dance group) or twice-weekly strength and balance exercise alone

(Chapter 5) or usual care offered a their homes (Chapter 4), respectively (control groups).

At baseline and after the intervention period of twelve weeks the groups were compared in

reference to their performance on walking (Chapter 4 and 5), their voluntary step execution

under single and dual task conditions (Chapter 4), and on their foot placement accuracy

during walking (Chapter 5). In both experiments the results revealed positive effects on

the performance of the tasks in favor of the dance group: a significant decrease of step

initiation time and step completion time in a voluntary step execution test under dual task

conditions (Chapter 4), a significant increase of gait velocity under dual task conditions,

and a significant positive within-group difference for foot placement accuracy in the dance

group (Chapter 5).

The findings arising from the interventions substantiate the hypothesis that physical

exercise enriched by an interactive and attention-demanding computer game can lead

to essential positive benefits in the physical performance of older adults under dual task

conditions when compared to traditional physical exercise. An exercise program that aims

to improve the physical performance under attention demanding circumstances should

consider a cognitively challenging element in addition to strength and balance exercise,

preferably in the form of an interactive computer game that is adapted to the participants’

abilities and needs. However, it still remains unclear to what extent the additional cognitive

input is responsible for the observed positive changes in physical performance in the

presented studies, which offers an incentive for further research on this topic.

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Chapter Eight

Zusammenfassung

Unser Körper ist ständig sowohl mit inneren (Muskelschwäche, Erkrankungen, Müdigkeit,

Gemütslage, kognitive Beeinträchtigungen, Sehschwächen) als auch mit äusseren

Einflussfaktoren (Hindernisse, Menschenmassen, Strassenverkehr, Wetter) konfrontiert.

Diese Faktoren stellen eine potentielle Gefahr für die Erhaltung des Körpergleichgewichts

dar. Der Einfluss dieser Faktoren verlangt von unserem Körper intakte kognitive Funktionen

um so potentielle Gefahrensituationen frühzeitig erkennen und eine angemessene

motorische Antwort auf die speziellen Gegebenheiten planen und auszuführen zu können.

Nur so ist es möglich einen Fehltritt oder gar einen Sturz zu verhindern. Nebst dem

Rückgang der körperlichen Funktionen wird ein Rückgang der kognitiven Funktionen,

welche diese Fähigkeiten steuern, als eines der Hauptgründe für Stürze bei älteren

Menschen vermutet. Es wurde bereits nachgewiesen, dass ältere Menschen im Vergleich zu

jüngeren Erwachsenen eine beeinträchtigte Leistungsfähigkeit unter Dual-Task-Situationen

aufweisen. Es wird vermutet, dass diese Beeinträchtigung teilweise einem Rückgang der

exekutiven Funktionen zuzuschreiben ist.

Ziel dieser Dissertation ist es herauszufinden, ob effektive Programme zur Sturzprävention

bei älteren Menschen Methoden einsetzen sollten, welche den kognitiven Rückgang

aufhalten und auf die Beeinträchtigungen der kognitiven Prozesse, mit Schwerpunkt auf

den exekutiven Funktionen, eingehen. Diese Frage basiert auf die wachsende Anzahl

der Studienergebnisse, die darauf hinweisen, dass die Kombination von kognitiver und

motorischer Aktivität, gegenüber der rein isolierten Ausübung der beiden Aktivitäten die

exekutiven Funktionen, insbesondere das Arbeitsgedächtnis und die Fähigkeit der geteilten

und selektiven Aufmerksamkeit, stärker fördern. Die Ergebnisse der Literaturübersicht

(Kapitel 3) machen deutlich, dass das Wissen über die Wirkung der kognitiv-motorischen

Methoden auf die körperliche Leistungsfähigkeit unter Single- und Dual-Task-Bedingungen

bei älteren Menschen noch sehr gering ist, was die Durchführung von Experimenten und

Interventionen mit einem kognitiv-motorischen Charakter in dieser Population rechtfertigt.

Zur Ergänzung des traditionellen körperlichen Trainings (Kraft- und

Gleichgewichtsübungen) wird in dieser Dissertation der Einsatz von interaktiven

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Computerspielen vorgeschlagen. Der Einsatz dieser Spiele ist aufgrund des

Zusammenspiels zwischen visuellen und propriozeptiven Informationen während des

Trainings äusserst wertvoll. Die Spieler erhalten wertvolle Rückmeldungen zur Qualität der

Bewegungsausführung und der Schwierigkeitsgrad kann relativ einfach an die Fähigkeiten

und Bedürfnisse der Trainierende angepasst werden. Das Computerspiel, welches in den

Interventionen dieser Dissertation zu Verwendung kam, ist ein interaktives Computer-

Tanzspiel (eine speziell modifizierte Version von StepMania, Version 3.9), welches auf

die Ausführung von präzisen und zeitlich getimten Schrittfolgen auf einer metallischen

Tanzplatte, aufgrund visueller und akustischer Reize basiert. Der Spieler beobachtet die

virtuelle Umgebung auf einem Bildschirm, auf welchem sich Pfeile vom unteren zum

oberen Ende bewegen und führt gemäss der angezeigten Pfeilrichtung Tanzschritte aus

(vorwärts, rückwärts oder zur Seite). Das Computer-Tanzspiel fördert die Koordination

der Körperbewegungen und schult gleichzeitig aber auch die Fähigkeit der geteilten

Aufmerksamkeit.

In zwei Interventionsstudien (Kapitel 4 und 5) absolvierten Senioren aus Schweizer

Altersheimen ein 12-wöchiges kognitiv-motorisches Trainingsprogramm, welches zweimal

pro Woche progressives Kraft- und Gleichgewichtsübungen und zusätzlich interaktives

Computer-Tanztraining beinhaltete (Tanzgruppe). Die Senioren der Kontrollgruppen

hingegen, absolvierten entweder ein rein motorisches Programm mit Kraft- und

Gleichgewichtsübungen zweimal pro Woche (Kapitel 5) oder besuchten weiterhin die

in den Altersheimen angebotenen Aktivitätsprogramme (Kapitel 4). Vor Beginn und

nach Beendigung der 12-wöchigen Trainingsphase wurden die Gruppen jeweils auf

ihre Gehleistung (Kapitel 4 und 5), ihre Fähigkeit der willentlichen Ausführung eines

Schrittes unter Single- und Dual-Task-Bedingungen (Kapitel 4) und die Genauigkeit ihrer

Fussplatzierung beim Gehen (Kapitel 5) getestet und miteinander verglichen.

Die Resultate beider Interventionsstudien zeigten positive Effekte in der Ausführung

der körperlichen Tests zugunsten der Tanzgruppe. Es resultierten eine signifikante

Verminderung der Schrittinitiierungs- und Schrittausführungszeit bei der willentlichen

Ausführung eines Schrittes unter Dual-Task-Bedingungen (Kapitel 4), eine signifikante

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Chapter Eight

Zunahme der Gehgeschwindigkeit unter Dual-Task-Bedingungen und eine signifikant

positive Veränderung der Genauigkeit der Fussplatzierung innerhalb der Tanzgruppe

(Kapitel 5).

Die Beobachtungen aus den beiden Interventionen bekräftigen die Hypothese, dass ein

körperliches Trainingsprogramm, welches durch ein interaktives und Aufmerksamkeit

förderndes Computerspiel im Vergleich zu traditionellem Training zu einem wichtigen

positiven Nutzen für die körperliche Leistungsfähigkeit von älteren Menschen unter Dual-

Task-Bedingungen führen kann. Ein Trainingsprogramm, welches zum Ziel hat die körperliche

Leistungsfähigkeit unter Aufmerksamkeit fördernden Bedingungen zu verbessern, sollte

ein zusätzliches kognitiv anspruchsvolles Element in die Kraft- und Gleichgewichtsübungen

integrieren. Dies idealerweise in Form eines interaktiven Computerspiels, welches auf die

Fähigkeiten und Bedürfnisse der älteren Menschen zugeschnitten ist. Allerdings bleibt noch

unklar in welchem Ausmass der zusätzliche kognitive Input für die beobachteten positiven

Veränderungen der körperlichen Leistungsfähigkeit der Teilnehmer in den vorgestellten

Studien verantwortlich ist, was eine Legitimation für weitere Forschung in diesem

Themengebiet ist.

195


Danksagungen

198

Chapter Eight

199

Danksagungen

Viele Leute haben zum Gelingen dieser Dissertation beigetragen. Im Folgenden möchte

ich mich bei denjenigen Leuten bedanken, die mich während der Zeit meines Doktorats

am Institut für Bewegungswissenschaften und Sport der ETH Zürich begleitet,

unterstützt und die Zeit so angenehm gestaltet haben.

Ein besonderer Dank gilt meinem Betreuer PD Dr. Eling de Bruin. Ich möchte mich bei

Dir für die einzigartige Unterstützung bedanken. Du hattest immer ein offenes Ohr für

alle Arten von Fragen und Problemen, ganz besonders auch in der letzten Phase meiner

Arbeit, in der ich nicht mehr am Institut anwesend war. Auch hast Du mich immer

wieder mit Deinem unerschöpflichen Optimismus angesteckt wenn es darum ging

schwierigen Reviewern entgegenzutreten und eine passende Lösung zu finden. Danke

für die Ermöglichung an zahlreichen internationalen Kongressen teilzunehmen und

die Einbindung in das alljährliche MOBEX Meeting, welches mir ermöglicht hat, meine

ersten Schritte in der Präsentation der eigenen Resultate vor einem fachkundigen,

aber toleranten und hilfsbereiten Publikum zu vollführen. Danke auch für Deine

unkomplizierte Art, die es einem ermöglicht auch bei der Arbeit viel Spass zu haben

und nicht immer alles so ernst zu nehmen.

Beim Institutsleiter und meinem Co-Referenten Prof. Dr. Kurt Murer möchte ich mich

dafür bedanken, dass er mir die Möglichkeit gegeben hat, am IBWS meine Doktorarbeit

zu schreiben. Kurt, insbesondere möchte ich mich bei Dir bedanken, dass Du am

IBWS eine lockere, freundschaftliche und verständnisvolle Atmosphäre unter allen

Mitarbeitern ermöglichst, wa ich sehr schätze.

Herr Prof. Dr. David P. Wolfer, bei Ihnen bedanke ich mich, dass Sie sich bereit erklärt

haben als Co-Referent für meine Doktorarbeit zu fungieren. Danke für Ihre Offenheit

sich auch mit Themen, welche ausserhalb Ihres Fachgebietes liegen zu begeistern.

Ohne die Mitarbeiter des IBWS wären die letzten vier Jahre nur halb so angenehm

gewesen:

Regula und Yvonne: Danke für die tolle Administrationsarbeit und eure Hilfsbereitschaft

– auch schon in den guten ‘alten’ Zeit im Kellersekretariat im ETH-Hauptgebäude.

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Chapter Eight

Rolf: Danke für Deine Unterstützung bei technischen und statistischen Fragen im Rahmen

meiner Studien. Ich bewundere Dich für Deine kreative Herangehensweise bei solchen

Dingen. Laura: Danke für Deine Gastfreundschaft und den vielen selbstgemachten

Leckereien mit denen Du uns regelmässig verwöhnt hast. Brigitte: Danke für Deine

Unterstützung bei wissenschaftlichen Fragen und Dein leckeres Johannisbeerkuchen-

Rezept. Jessica: Danke, dass ich Dir gleich am ersten Arbeitstag den Fensterplatz

„klauen“ durfte. Danke für die gute Zeit als Nachbarn und auch für die Zeit, in der uns

ein hohes Bücherregal trennte. Simon: Danke für unsere manchmal sinnvolle, aber auch

sinnlose Diskussionen über Gott und die Welt. Dank Dir werde ich nie mehr vergessen die

Hintergrundebene im Photoshop zu duplizieren. Der Dank geht auch an Sara, Monika,

Roger, Roli und Oli, die zum guten Arbeitsklima am IBWS beigetragen haben.

Ganz besonders möchte ich mich bei meinen ‘Doktoratsgspänlis’ bedanken:

Andrea wir haben die Hochs und Tiefs des ‘Doktorandendaseins‘ fast vom selben Tag

an zusammen durchlebt. Wir haben immer versucht, uns gegenseitig so gut es ging zu

helfen. Ich danke Dir für die tolle Zeit, die wir miteinander am Institut erleben durften.

Dank für Deine Hilfsbereitschaft, Deine Echtheit und Dein Vertrauen Sam während Deinen

Experimenten hüten zu dürfen und Deine Offenheit während unseren Gesprächen über

Dinge, die das Leben so mit sich bringt. Ich hoffe Du konntest von mir eine kleine Portion

‘Ironie’ mit auf den Weg nehmen. Liebe Eva, heute denke ich nicht mehr, dass wir als die

‘dümmsten’ Doktoranden in der Geschichte der ETH eingehen werden, denn wir haben in

den gemeinsamen Jahren am IBWS viel erarbeitet und geleistet. Bewundert habe ich dabei

immer Deine Zielstrebigkeit und Dein Organisationstalent. Ein grosses Dankeschön für

Deine Mithilfe bei den Tests und für das Einspringen beim Leiten von Trainingslektionen.

Danke für Deine Mithilfe in der Organisation der Probanden und Räumlichkeiten für

die Durchführung der Reliabilitätsstudie in Feusisberg, das weiss ich sehr zu schätzen.

Ich wünsche Dir für Deine Zukunft als Mami und Geschäftsfrau von Herzen alles Gute.

Rahel Du warst der sichere Wert am IBWS. Wenn alle schon den Feierabend genossen

oder frei machten, warst Du noch mit mir im Büro. In der Zeit am Institut haben wir viele

201

Danksagungen

Gemeinsamkeiten entdeckt, z. B. das Ärgernis von ‘Nespresso-Kapseln-stecken-lassen-

bis-sie-so-fest-kleben-dass-sie-nicht-mehr-von-alleine-runterfallen’. Du hattest in Deinem

ersten Jahr leider etwas Pech mit Deinem Thema, ich wünsche Dir für Deinen zweiten

Anlauf alles Gute und viel Erfolg. Danke auch Dir Seline für die gemeinsame Zeit am

IBWS. In der kurzen Zeit konnte ich Dich als eine warmherzige, aufgestellte und fleissige

Person kennenlernen. Unsere Aufenthalte in Trondheim und Manchester und unseren

Ghetto-Gruss am Morgen und am Abend werde ich in guter Erinnerung behalten. Auch

Dir viel Erfolg bei Deiner Arbeit und ‘keep on running’. Lieber Patrick, leider hatten wir

nicht oft die Gelegenheit uns besser kennenzulernen. Ich wünsche Dir alles Gute für

Deine Doktorarbeit und danke, dass Du meine Arbeit mit den Tanzplatten am Institut

weiterverfolgst.

Ein spezieller Dank geht auch an Andrew Fraser. Ich bin Dir sehr dankbar für das englische

‘proof-reading‘ des Manuskripts dieser Doktorarbeit. Bleibe weiterhin so interessiert und

begeistert für neue Themen.

Danke auch an alle, die im Rahmen der Studien mitgeholfen haben, sei es bei der Mithilfe

bei der Durchführung der Tests, bei der Leitung der Trainingsstunden oder bei der

Bereitstellung der Räumlichkeiten: Amos Coppe, Angela Nägeli, Tatjana Diener, Simone

Karmann, Turgut Gülay, Manuela Nötzli, Melanie Ramp, Rosina Landolt, Susan Brouwer,

Gerhard Ineichen, Marie-Louise Sarraj, Hans van het Reve und danke allen Teilnehmern

und Mitarbeitern des Alterszentrum am Etzel in Feusisberg, des Zentrum Breitenhof in

Rüti, des Alterszentrum Lanzeln in Stäfa, der Altersheime Limmat und Stampfenbach in

der Stadt Zürich.

PhD Curriculum

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Chapter Eight

205

PhD Curriculum

PhD Curriculum

Peer-reviewed publications:

de Bruin ED, Schoene D, Pichierri G, Smith ST. Use of virtual reality technique for the


Geriatr. 2010 Aug; 43(4):229-34.

Pichierri G, Wolf P, Murer K, de Bruin ED. Cognitive and cognitive-motor interventions

affecting physical functioning: A systematic review. BMC Geriatrics 2011,11:29.

Pichierri G, Coppe A, Lorenzetti S, Murer K, de Bruin ED. The effect of a cognitive-motor

intervention on voluntary step execution under single and dual task conditions in

older adults: a randomized controlled pilot study. Clinicial Interventions in Aging,

2012:175–184.

Pichierri G, Murer K, de Bruin ED. A cognitive-motor intervention using a dance video

game to enhance foot placement accuracy and gait under dual task conditions in older

adults: a randomized controlled trial. BMC Geriatrics 2012,12:74.

Pichierri G, Diener T, Murer K, de Bruin ED. Assessment of the test-retest reliability of a

foot placement accuracy protocol in assisted-living older adults. Gait & Posture 38 (2013)

784–789.

Other publications:

Slavko R, Pichierri G, de Bruin ED. Denk-Sport – Dual-Tasking-Training mindert

Sturzrisiko. Physiopraxis 2011, 10:34-37 & Ergopraxis 2012, 3/12.

206

Chapter Eight

Presentations:

Oral presentation at the 1st Joint World Congress ISPGR and GMF in Trondheim (Norway),

June 28th, 2012: “The effects of computer game dancing on voluntary step execution in

older adults”.

Oral presentation at the 15th MOBEX Meeting 2012 in Zurich, Switzerland, January 13th,

2012: “The effects of a cognitive motor exercise intervention on voluntary step execution

and step accuracy in older adults”.

Oral presentation at the 14th MOBEX Meeting 2011 in Glasgow, Scotland UK, January 14th,

2011: “Cognitive and cognitive-motor interventions affecting motor functioning of older

adults: a systematic review”.

Poster presentation at the 16th annual Congress of the European College of Sport Science

(ECSS) in Liverpool UK, July 7th, 2011: “Cognitive and cognitive-motor interventions affec-

ting motor functioning of older adults: a systematic review”.

Poster presentation at the 4. Jahrestagung der Sportwissenschaftlichen Gesellschaft der

Schweiz (SGSS) in Magglingen, Switzerland, March 1–2, 2012: “The effect of a cognitive-

motor intervention on voluntary step execution under single and dual task conditions in

older adults: a randomized controlled pilot study”.

Visited congresses:

3rd International Congress on Gait & Mental Function – The interplay between walking,

behavior and cognition. Washington D.C., USA, February 26–28, 2010.

14th MOBEX Meeting 2011 in Glasgow, Scotland UK, January 14–15, 2011.

16th annual Congress of the European College of Sport Science (ECSS), Liverpool,

England UK, July 6–9, 2011.

15th MOBEX Meeting 2012 in Zurich, Switzerland, January 13–14, 2012.

1st Joint World Congress ISPGR and GMF in Trondheim (Norway), June 24–28, 2012.

16th MOBEX Meeting 2013 in Manchester, England UK, January 13–14, 2013.

207

PhD Curriculum

Curriculum vitae

210

Chapter Eight

211

Curriculum vitae

About the author

Name Giuseppe Pichierri

Date of birth July 6th 1979 in Bülach, Switzerland

Citizen of Niederglatt, Zurich, Switzerland

Sava, Taranto, Italy

Education

2009 – 2014 PhD in Science at the Institute of Human Movement Sciences and

Sport, ETH Zurich, Switzerland

2006 – 2008 Master of Science Degree in Human Movement Sciences and Sport ETH

Zurich with Major in Motor Control and Motor Learning

2002 – 2006 Bachelor of Science Degree in Human Movement Sciences and Sport,

ETH Zurich

1995 – 2000 Academic Upper Secondary School, Matura Type D (modern languages)

Master thesis and academic internships

01 – 07/2008 Master thesis ETH Zurich, Switzerland

“Factors related to the reduced physical activity in patients with

hematological malignancies”

In collaboration with the University Hospital Zurich

09 – 12/2007 Academic internship II in oncological rehabilitation in the Clinic for

Rheumatic Diseases and Physical Medicine at the University Hospital

Zurich, Switzerland

03 – 06/2007 Academic internship I in neuropsychology at the Institute for Neuro-

psychology of the University of Zurich, Switzerland

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